Flow cytometric DNA ploidy analysis of squamous cell carcinoma of the oral cavity. Comparison with clinical staging and histologic grading

Correlation Between Histological Grading and Ploidy Status in Oral Leukoplakia, Oral Submucous Fibrosis, and Oral Squamous Cell Carcinoma: A Flow Cytometric Analysis

Background:

Methods to analyze progression of carcinogenesis and stage of cancer are vital nowadays due to the high prevalence of these lesions. DNA ploidy analysis is one such important method in early diagnosis and improving prognosis.

Aims and Objectives:

The aim of this study was to correlate histopathological grading and DNA ploidy in oral leukoplakia, oral submucous fibrosis (OSMF), and oral squamous cell carcinoma (OSCC) cases.

Materials and Methods:

Our study included 80 subjects, grouped into 4 groups of 20 each of OSCC, leukoplakia, OSMF, and healthy individuals. Histopathological grading was carried out in study cases, DNA ploidy was estimated using flow cytometry, and both the findings were correlated.

Results:

Among the 20 cases of leukoplakia group, 6 cases showed aneuploidy and 14 showed diploidy. In the 20 cases of OSF group, 2 cases showed aneuploidy and 18 showed diploidy, and in the 20 cases of OSCC group, 10 showed aneuploidy and 10 showed diploidy. Most of the aneuploidy cases showed severe dysplasia.

Conclusion:

Analysis of DNA ploidy status can serve as a diagnostic tool for early detection of malignancies owing to the subjective nature of traditional histopathological grading.

Prostate Cancer: A Correlative Study of Multiparametric MR Imaging and Digital Histopathology

Purpose To correlate multiparametric magnetic resonance (MR) imaging and quantitative digital histopathologic analysis (DHA) of the prostate. Materials and Methods This retrospective study was approved by the local institutional review board and was HIPAA compliant. Forty patients (median age, 60 years; age range, 44-71 years) who underwent prostate MR imaging consisting of T2-weighted and diffusion-weighted (DW) MR imaging along with subsequent robot-assisted radical prostatectomy gave informed consent to be included. Whole-mount tissue specimens were obtained with a patient-specific mold, and DHA was performed to assess the lumen, epithelium, stroma, and epithelial nucleus. These DHA images were registered with MR images and were correlated on a per-voxel basis. The relationship between MR imaging and DHA was assessed by using a linear mixed-effects model and the Pearson correlation coefficient. Results T2-weighted MR imaging, apparent diffusion coefficient (ADC) of DW imaging, and high-b-value DW imaging were significantly related to specific DHA parameters (P < .01). For instance, lumen density (ie, the percentage area of tissue components) was associated with T2-weighted MR imaging (slope = 0.36 ± 0.05 [standard error], γ = 0.35), ADC (slope = 0.47 ± 0.05, γ = 0.50), and high-b-value DW imaging (slope = -0.44 ± 0.05, γ = -0.44). Differences between regions harboring benign tissue and those harboring malignant tissue were observed at MR imaging and DHA (P < .01). Gleason score was significantly associated with MR imaging and DHA parameters (P < .05). For example, it was positively related to high-b-value DW imaging (slope = 0.21 ± 0.16, γ = 0.18) and negatively related to lumen density (slope = -0.19 ± 0.18, γ = -0.35). Conclusion Overall, significant associations were observed between MR imaging and DHA, regardless of prostate anatomy. ^© RSNA, 2017 Online supplemental material is available for this article.

Chromosomal instability, aneuploidy and routine high-resolution DNA content analysis in oral cancer risk evaluation

Carcinogen exposure of the oral cavity is thought to create an extensive 'field cancerization'. According to this model, a very early precursor of oral cancer is a patch of normal-appearing mucosa in which stem cells share genetic/genomic aberrations. These precancerous fields then become clinically visible as white and red lesions (leuko- and erythro-plakias), which represent the vast majority of the oral potentially malignant disorders. This review focuses on aneuploidy (where it is from) and on biomarkers associated with DNA aneuploidy in oral mucosa and oral potentially malignant disorders, as detected by DNA image and flow cytometry. Data from the literature strongly support the association of DNA ploidy with dysplasia. However, work is still needed to prove the clinical value of DNA ploidy in large-scale prospective studies. Using high-resolution DNA flow cytometry with fresh/frozen material and the degree of DNA aneuploidy (DNA Index) might improve the prediction of risk of oral cancer development.

Chromosomal instability, DNA index, dysplasia, and subsite in oral premalignancy as intermediate endpoints of risk of cancer

BACKGROUND

Chromosomal instability and aneuploidy may represent biomarkers of oral exposure to damaging agents and early signs of clinical disease according to the theory of "oral field cancerization."

METHODS

The hypothesis was tested that the DNA index (DI) values, obtained by high-resolution DNA flow cytometry (DNA-FCM), may potentially contribute to oral cancer risk prediction. For this purpose, the DI of oral fields of normal-appearing mucosa and oral potentially malignant disorders (OPMDs) in 165 consecutive patients was tested for association with dysplasia and/or the oral subsites of tongue and floor of the mouth taken as high-risk intermediate endpoints surrogate of cancer clinical endpoints. The association was evaluated by logistic regression using patient gender, age, tobacco, cigarette smoking habit, and alcohol abuse as confounding variables.

RESULTS

Different DI models provided evidence of statistical significant associations. Subdividing the DI values in diploid, near-diploid aneuploid, and high or multiple aneuploid from both OPMDs and oral normal-appearing mucosa, ORs, respectively, of 1, 4.3 (P = 0.001), and 18.4 (P < 0.0005) were obtained.

CONCLUSION

Routine DI analysis by high-resolution DNA-FCM seems potentially useful to complement dysplasia and subsite analysis for assessment of oral cancer risk prediction and for a better management of the patients with OPMDs. Work is in progress to validate the present findings in a prospective study with clinical endpoints.

IMPACT

Identifying DNA abnormalities in oral premalignancy may lead to biomarkers of oral exposure and cancer risk and potentially to more effective prevention measures.

Correlation between dysplasia and ploidy status in oral leukoplakia

Oral leukoplakia and other potentially malignant disorders (PMD) may progress to oral squamous cell carcinoma (OSCC). The gold standard for assessing the potential for malignant transformation remains histologic examination with the aim of grading the dysplastic changes. However, not all lesions with dysplasia will progress to OSCC. DNA ploidy has been suggested as a method to predict the clinical behaviour of PMD. This study reports on the use of high-resolution flow cytometry to determine the ploidy status of formalin-fixed, paraffin-embedded material from PMD compared to their dysplasia grade on histology. Aneuploidy was found in 13 % of mild, 31 % of moderate, and 54 % of severe dysplasia cases. This difference was statistically significant (p = 0.011). The differences in ploidy status were more significant when grouping the dysplasia into low-risk and high-risk categories (p = 0.008). These findings indicate that the ploidy status of PMD as determined by high-resolution flow cytometry may be of value in predicting biological behaviour in PMD such as leukoplakia.

pRB, a tumor suppressor with a stabilizing presence

The product of the retinoblastoma tumor-susceptibility gene (RB1) is a key regulator of cell proliferation and this function is thought to be central to its tumor suppressive activity. Several studies have demonstrated that inactivation of pRB not only allows inappropriate proliferation but also undermines mitotic fidelity, leading to genome instability and ploidy changes. Such properties promote tumor evolution and correlate with increased resistance to therapeutics and tumor relapse. These observations suggest that inactivation of pRB could contribute to both tumor initiation and progression. Further characterization of the role of pRB in chromosome segregation will provide insight into processes that are misregulated in human tumors and could reveal new therapeutic targets to kill or stall these chromosomally unstable lesions. We review the evidence that pRB promotes genome stability and discuss the mechanisms that probably contribute to this effect.

Alpha-smooth muscle actin within epithelial islands is predictive of ameloblastic carcinoma

Ameloblastoma is the most common clinically significant odontogenic tumor. It is considered benign but locally invasive and associated with variable clinico-pathological behavior. Ameloblastic carcinoma is a malignant tumor having features of ameloblastoma in addition to cytologic atypia with or without metastasis. It is aggressive and associated with poor prognosis. The aim of this study was to examine which epithelial and stromal markers are predictive of histologically diagnosed ameloblastic carcinoma and can sufficiently differentiate it from solid/multicystic ameloblastoma (SA). We examined immunohistochemically Ki-67, epithelial membrane antigen (EMA), alpha-smooth muscle actin (alpha-SMA), calponin, p63 and DNA content using image (ICM) and flow cytometry (FCM) in three ameloblastic carcinomas and up to 18 SAs. The important findings were that Ki-67 labeling index was significantly higher in ameloblastic carcinoma than SA while EMA, calponin, p63, ICM and FCM did not sufficiently differentiate the two groups of lesions. Expression of alpha-SMA was consistently obtained within the epithelial island cells of ameloblastic carcinoma and not in SA, although the marker was well expressed in the stroma of both lesions. We therefore conclude that the presence of alpha-SMA within the epithelial islands is highly predictive of ameloblastic carcinoma.

Evaluation of nuclear morphometry and DNA ploidy status for detection of malignant and premalignant oral lesions: quantitative cytologic assessment and review of methods for cytomorphometric measurements

PURPOSE

Detection of a precancerous or cancerous lesion when small is one of the most important factors to improve 5-year survival rates of oral cancer. Although surgical biopsy is the most definitive method for diagnosing oral lesions, it is impractical to routinely subject large numbers of patients to biopsy. Recently, cytomorphometric assessments improved by advanced computer-assisted image analysis systems have gained importance. This study was established to evaluate the efficacy of nuclear cytomorphometric analysis and DNA ploidy status for the detection of oral malignancies. Methods used for cytomorphometric analysis were also reviewed.

PATIENTS AND METHODS

Oral mucosal smears (n = 44) were obtained from patients (n = 22) presenting with various oral lesions using a cytobrush immediately before biopsy. Cytomorphometric measurements and nuclear Feulgen DNA content analysis were carried out after the Feulgen staining procedure. Smears from the lesion site constituted the study group whereas contralateral healthy mucosal sites served as control.

RESULTS

DNA ploidy analysis revealed 20 diploid (90.9%) and 2 aneuploid DNA patterns (9.1%) sampled from the lateral margin of the tongue and floor of the mouth. When only malignant lesions were considered, aneuploidy rate was 16.7% whereas a diploid pattern was indicated for 83.3% of the sample. With cytomorphometric measurements, a statistically significant difference was shown for nuclear perimeter, area, diameter equivalent to circle, minimum and maximum Feret, intensity, DNA content (c) and DNA index values.

CONCLUSIONS

Cytomorphometric analysis via oral brush biopsy is a valuable adjunct to biopsy for identification of premalignant and early stage cancerous oral lesions as a rapid and minimally invasive procedure with high specificity and sensitivity rates, requiring no topical or local anesthetic.

DNA histochemical analysis in oral squamous cell carcinoma

BACKGROUND

Recent years have witnessed an increasing emphasis on the role of nuclear DNA and its application in experimental pathological diagnosis to predict prognosis and management of certain neoplasm.

AIMS

to establish objective criteria for the degree of differentiation and histochemical quantitative of nuclear DNA of oral squamous cell carcinoma (OSCC) using microspectrophotometric analysis.

MATERIAL AND METHODS

The study was conducted on histologic materials from patient with OSCC. Two histological grading systems were used; Broder's and invasive front grading system were recorded. Microspectrophotometry was applied on Feulgen-stained sections to determine the quality of tumour nuclear DNA content in two different histological grading systems of OSCC.

RESULTS

Nuclear DNA content increased significantly with decreasing tissue differentiation as well with increasing tumour size.

CONCLUSION

The grading system and DNA content provides more objective and accurate criteria which relate the morphologic finding to biologic activity and growth patterns of oral cancer as compared to histologic differentiation alone.

Possible role of stromal-cell-derived factor-1/CXCR4 signaling on lymph node metastasis of oral squamous cell carcinoma

We examined the role of chemokine signaling on the lymph node metastasis of oral squamous cell carcinoma (SCC) using lymph node metastatic (HNt and B88) and nonmetastatic oral SCC cells. Of 13 kinds of chemokine receptors examined, only CXCR4 expression was up-regulated in HNt and B88 cells. CXCR4 ligand, stromal-cell-derived factor-1alpha (SDF-1alpha; CXCL12), induced characteristic calcium fluxes and chemotaxis only in CXCR4-expressing cells. CXCR4 expression in metastatic cancer tissue was significantly higher than that in nonmetastatic cancer tissue or normal gingiva. Although SDF-1alpha was undetectable in either oral SCC or normal epithelial cells, submandibular lymph nodes expressed the SDF-1alpha protein, mainly in the stromal cells, but occasionally in metastatic cancer cells. The conditioned medium from lymphatic stromal cells promoted the chemotaxis of B88 cells, which was blocked by the CXCR4 neutralization. SDF-1alpha rapidly activated extracellular signal-regulated kinase (ERK)1/2 and Akt/protein kinase B (PKB), and their synthetic inhibitors attenuated the chemotaxis by SDF-1alpha. SDF-1alpha also activated Src family kinases (SFKs), and its inhibitor PP1 diminished the SDF-1alpha-induced chemotaxis and activation of both ERK1/2 and Akt/PKB. These results indicate that SDF-1/CXCR4 signaling may be involved in the establishment of lymph node metastasis in oral SCC via activation of both ERK1/2 and Akt/PKB induced by SFKs.

Comparison of DNA content parameters in paired, fresh tissue pretreatment biopsies and surgical resections from squamous cell carcinoma of the head and neck

OBJECTIVE

Cellular DNA characteristics derived from pretreatment biopsy (PTB) may become important for predicting treatment outcomes in patients with head and neck squamous cell cancer (HNSCC). Whether the PTB adequately represents the whole specimen is of critical importance.

STUDY DESIGN

In a series of >700 HNSCCs, we identified 59 cases in which the PTB and the surgical resection (SR) met the following criteria: PTB and SR were from the same site, and SR was obtained within 5 weeks of PTB with no intervening treatments.

RESULTS

Twenty-nine percent of the PTB specimens were DNA diploid. Only 1 of the 11 subsequent DNA diploid SR was associated with a DNA aneuploid PTB (91% concordance). Of the 48 DNA aneuploid tumors, 3 were associated with DNA diploid PTB (94% concordance). Three other DNA aneuploid SRs were associated with PTB of poor quality.

CONCLUSION

With respect to DNA ploidy, PTB are representative of SR specimens.

Can flow cytometrically determined DNA ploidy and S-phase fraction predict regional metastasis in squamous cell carcinoma of the oral cavity?

BACKGROUND

The value of flow cytometric analysis of DNA ploidy and S-phase fraction (SPF) as an indicator of regional metastasis in oral cancer is currently being debated. Intratumoral heterogeneity makes this problem complex.

METHODS

Intratumoral DNA ploidy heterogeneity and intratumoral SPF variation were examined using multiple specimens from 31 surgically resected specimens taken from patients with oral cancer without preoperative therapy. Flow cytometric analysis of single biopsy specimens from 79 patients with oral cancer was also undertaken to ascertain their value as indicators of regional metastasis.

RESULTS

Forty-five percent (14 of 31) of tumors showed intratumoral ploidy heterogeneity. Intratumoral SPF variation in the 31 tumors ranged from 0.2% to 6.9% (mean, 3.3%). Multivariate analysis showed that a SPF greater than 27% was the most important parameter for predicting regional metastasis.

CONCLUSIONS

DNA ploidy is heterogeneous within a tumor, whereas SPF is relatively stable and can be correlated with regional metastasis in oral cancer.

Maspin expression in stage I and II oral tongue squamous cell carcinoma

BACKGROUND

A relatively high failure rate in the therapy of patients with early oral tongue squamous cell carcinomas (SCCs) is evidenced by untreated clinically negative neck lymph node metastasis. It is important to predict the malignant potential of oral tongue SCC in stage I and II patients, because the development of lymph node metastasis directly affects the prognosis of the patients.

METHODS

We evaluated maspin expression immunohistochemically in patients with stage I and II oral tongue SCCs and determined whether the expression level may be a useful factor in predicting metastatic potential and prognosis of these SCCs.

RESULTS

Clinical follow-up data showed a longer disease-free interval and overall survival periods for tumors immunohistochemically positive for maspin than for tumors negative for maspin, with the difference in disease-free interval being statistically significant (p =.01). The absence of maspin expression was found more frequently in cases of subsequent cervical lymph node metastasis than in cases without metastasis (p =.03).

CONCLUSIONS

Decreased maspin expression may be a significant factor associated with the metastatic potential of stage I and II oral tongue SCCs.

DNA ploidy and cyclin D1 expression in basal cell carcinoma of the head and neck

Basal cell carcinomas (BCCs) may be subdivided into primary with a favorable biologic course (BCC1) and recurrent and/or metastatic (BCC2). No clear association between primary tumor location, histologic subtype, or other clinicopathologic variables and predisposition for BCC2 has been found. Histopathologic criteria are limited for prognostication. To identify prognostic factors useful for planning therapy, we studied cyclin D1 immunohistochemical expression, DNA ploidy, and epiluminescence light microscopic (ELM) patterns in 60 cases of BCC (30 BCC1 and 30 BCC2) in the head and neck region, half of which were hyperpigmented. Cyclin D1 was absent in 27 cases, expressed at low level in 4 cases, and overexpressed in 30 cases. Seven BCCs were euploid, 28 exhibited a mixed cellular population, and 25 were aneuploid. Among aneuploid tumors, hypodiploidy was found in 12. Among the 30 pigmented carcinomas, only 15 showed a typical ELM pattern. No association between pigmentation and more aggressive biologic behavior of BCC was found. These results and follow-up data seem to indicate that an unfavorable outcome can be predicted by hyperexpression of cyclin D1, aneuploidy, and an atypical ELM pattern for pigmented cases. A definite hypodiploid peak was associated with worse prognosis. The analysis of cyclin D1 expression and DNA ploidy may help identify BCC with an aggressive phenotype and a poor clinical outcome.

Characterization of epithelial cell activity in patients with oral cancer

Accurate, predictive assessment of the clinical behaviour and progression of individual oral cancers and premalignant lesions requires reproducible and quantitative analyses of diseased tissue. In this paper we describe the use of in vitro double labelling (sequential tritiated thymidine and bromodeoxyuridine staining of proliferating epithelial cells) to calculate S phase labelling indices (LIs), estimation of S phase duration (tS), and measurement of variables of flux to and from S for excised specimens of oral squamous cell carcinoma, premalignant lesions, and clinically normal mucosa from patients with oral cancer. There was a significant increase in mean LIs in buccal mucosa leukoplakias (14.5%) compared with normal mucosa (10.3%); P = 0.03. LIs were also increased in patients with cancers of the floor of mouth and ventral tongue but neither these changes nor alterations in flux parameters or S Phase durations were significant. Twenty-one kinetic profiles of dysplastic and malignant tissue were compared with conventional histopathological results, however, and these showed a 2.2% increase in LIs with each increase in grade of dysplasia (P = 0.004) and a 12% increase in LIs with each reduction in tumour differentiation (P = 0.02).

Flow cytometric DNA ploidy analysis of oral cancer comparison with histologic grading

It has been reported that DNA content analysis provides prognostic information eliminating the subjective component involved in routine microscopic decision making. In an attempt to establish a relationship between pathological findings and flow cytometric analysis, 36 formalin-fixed, paraffin-embedded tumour tissue samples were prepared according to Hedley's method and analysed by means of an Epics Profile II flow cytometer. DNA aneuploidy was observed in 15 tumours (41%). A statistically significant correlation was identified between DNA index and mitoses, cellular response and degree of differentiation, but not the ploidy status. It was not possible to identify a significant association of sex, age, and site of the tumour to DNA index. We found a strong correlation between histologic malignancy and DNA index; an increase in DNA index as malignancy score increases was noted. It was concluded that DNA index shows a good correlation with the histologic features of oral cancer, being a complement of differentiation and histologic grading analysis. The use of DNA analysis as a complement to pathological studies would help to diminish the subjective component of assessment of head and neck cancers. Ploidy status was not statistically associated with the differentiation of tumours.

Overexpression of cyclin-D1, bcl-2, and bax proteins, proliferating cell nuclear antigen (PCNA), and DNA-ploidy in squamous cell carcinoma of the oral cavity

The prognostic role of the expression of bcl-1, bcl-2, bax, PCNA, and DNA-ploidy in a series of 25 oral squamous cell carcinoma (SCC) was investigated. The average age of the patients was 62.04 years (range, 27 to 81 years), with a sex ratio (M/F) of 23:2. The follow-up mean time was 2.24 years (range, 8 months to 8 years from surgery). Immunohistochemistry for PCNA, bcl-2, bcl-1, and bax proteins was carried out on 5-microm serial sections from formalin-fixed, paraffin-embedded tissue. The findings were compared with clinicopathologic data and with follow-up. The statistical evaluation of the results of the current study suggests that the low positivity for PCNA with a high positivity for bcl-2 protein are related to a better clinical behavior of the tumors. By converse, a high expression of PCNA, bax, and bcl-1 appears to correlate with a worse prognosis. All of our cases of SCC showed the presence of aneuploid populations, which was not correlated with the clinicopathologic parameters or with the overexpression of bcl-1, bcl-2, bax, and PCNA. Therefore, the aneuploidy per se did not predict the clinical evolution for the single cases of cancers. Nevertheless, once the parameters considered for the evaluation of DNA were examined in detail, it appeared that some of them, individually or combined with each other or with the expression of bcl-1, bcl-2, and bax, gained statistical significance in predicting the clinical evolution of SCC of our series. Particularly, high values of 2cDI and DNA-MG and the absence or reduction of the euploid population were associated with a short interval between surgery and recurrence or death, and this significance persisted when the simultaneous presence of overexpression of bcl-1 was considered.

Prognosis in lower lip squamous cell carcinoma: assessment of tumor factors

We studied a consecutive series of 54 cases of lower lip squamous cell carcinoma (LLSCC) in order to identify any variables which might predict the development of lymph node metastases. The cases were divided into 38 tumors without metastases (group I) and 16 tumors with lymph node metastases (group II). The following factors were investigated: tumor size, histologic grading maximal thickness, perineural invasion, DNA ploidy and PCNA expression. In conclusion, we found that LLSCC greater than 2 cm in diameter, with histological grading G3-G4, thickness of more than 6 mm, DNA aneuploidy and high PCNA expression (PCNA LI > 0.48), were at high risk for the development of lymph node metastases.

Tumor DNA content as a prognostic indicator in squamous cell carcinoma of the oral cavity and tongue base

BACKGROUND

Nuclear deoxyribonucleic acid (DNA) content is a prognostic factor in several tumors, and decisions regarding treatment have been made using this parameter. Nevertheless, there is no agreement in head and neck cancer. The purpose of the present study was to ascertain whether tumor DNA content correlated with prognosis in cases of primary squamous cell carcinoma (SCC) of the oral cavity and tongue base.

METHODS

A retrospective study of formalin-fixed, paraffin-embedded tissue from patients with histologically confirmed SCC of the oral cavity and tongue base was performed using flow cytometry. Tumor DNA content was studied in 109 sets of specimens from previously untreated patients. All of them underwent surgical resection at the University "Hospital de La Princesa" between 1982 and 1992. Clinical parameters (age, sex, site of primary tumor, clinical stage, adjuvant therapy received, and disease-free and overall survival) and histologic parameters (histopathologic stage, tumor differentiation, type of inflammatory infiltration, presence of perineural invasion) were recorded in all cases. An exhaustive statistical analysis was applied.

RESULTS

Only the histograms of 93 patients were adequate for consideration. In flow cytometric analysis, DNA aneuploidy was observed in 51 tumors (55%). The proportion of aneuploid tumors was significantly higher in advanced-stage carcinomas (p < .05), tumors with perineural invasion (p < .05) and in men (p < .05). In the 24 patients with lymph node metastasis, the incidence of aneuploidy was 82% (19 of 24) (p < .05). The rate of metastasis and aneuploidy increased as the degree of differentiation decreased (p < .05 for both). Patients with aneuploid carcinomas in both early and advanced stages had shorter relapse-free and overall survival periods than did the patients with diploid tumors (p < .001 for both). A Cox regression analysis demonstrated that ploidy was the single most important prognostic factor in determining relapse and death (p < .001 for both).

CONCLUSIONS

The results indicate that tumor DNA analysis by flow cytometry appears to be useful as a supplement to clinical and histologic evaluation in predicting the tendency of SCC of the oral cavity and tongue base to metastasize to regional lymph nodes and to predict the outcome of the disease.

The value of DNA flow cytometry in predicting the development of lymph node metastasis and survival in patients with locally recurrent oral squamous cell carcinoma

BACKGROUND

DNA flow cytometry studies of squamous cell carcinoma of the head and neck have shown that patients with diploid tumors have favorable prognoses, whereas the outcomes of those with, aneuploid tumors are poor. This study was conducted to examine the importance of DNA ploidy in patients with locally recurrent oral carcinoma.

METHODS

DNA flow cytometry was performed on 93 primary oral carcinomas and their subsequent recurrences.

RESULTS

Eight patients with diploidy of both the primary tumor and the recurrence never developed lymph node metastasis. The 5-year overall survival rate of this group was 87%. For 80 aneuploid primary carcinomas, recurrences developed that were also aneuploid. Only 31% of these patients were 5-year survivors (P < 0.001). Lymph node metastasis at presentation was found in 55% of this group, whereas 13% of initially lymph node negative patients presented with regional disease at second surgery. Five of 13 diploid primary tumors recurred with aneuploid cell lines. Three of these five patients died, two with regional metastasis. The 5-year survival rate of patients with aneuploid recurrences who were never afflicted with lymph node involvement (41%) was better (P < 0.05) than the 5-year survival rate of those with metastasis at presentation or at second surgery (26%).

CONCLUSIONS

The excellent prognosis of patients with diploid primary tumors can be reestablished by treating local recurrences with radical surgery, if the surgery is performed before aneuploid cell lines have emerged. It appears that aneuploid tumor cell lines acquire unique properties that make them capable of invasion and metastasis.

DNA ploidy analysis of squamous cell carcinomas of the oral and maxillofacial region: clinical and pathologic correlations

DNA ploidy was investigated in 61 specimens obtained from 25 patients with squamous carcinoma of the oral and maxillofacial region. Biopsy specimens of normal tissue surrounding the tumor were also obtained in six patients. Single-cell suspensions for flow cytometric analysis were prepared. The DNA ploidy and histogram were calculated and compared with the histologic grade, presence of lymph node metastases, and course of the disease. The ploidy of the main stemline was peridiploid in 17 carcinomas, hyperdiploid in three, and aneuploid in five. Histologic grade but not nodal involvement was associated with the ploidy of the main stemline. Of 15 multisampled carcinomas 13 showed constant DNA ploidy and histogram classification. In the other two major changes in DNA ploidy (from peridiploid to hyperdiploid in the first and from peridiploid to aneuploid in the second) were found. Survival information was available for 24 patients. Ploidy values higher or lower than 2.5 c were strongly predictive of both overall (p < 0.001) and relapse-free survival (p < 0.001). The lymph node status proved a powerful prognostic indicator (p = 0.014) but was not related to the relapse-free time of survival. Multiparametric evaluation of survival revealed an independent role of both DNA ploidy and nodal involvement in the prognosis of squamous carcinoma of the oral and maxillofacial region.

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

BACKGROUND

Prognostic indicators that could assist in a more precise selection of patients with oral cancer for differentiated therapy would be clinically valuable.

METHODS

A consecutive series of 161 cases of intraoral squamous cell carcinoma (SCC) occurring during a 5-year period in a population of 1.4 million inhabitants, was evaluated by histopathologic (the modified classification of Jakobsson et al.), stereologic, clinical, and epidemiologic parameters and the serum markers hemoglobin and rhesus blood group.

RESULTS

Univariate analysis established a significant prognostic value in terms of cause-specific survival for T stage (P < .0001), stage (P < .0001), maximum tumor diameter (P < .0001), N stage (N+/NO) (P < .0001), alcohol consumption (P = .03), stereologic estimates of nuclear volume (P = .04), and the histomorphologic parameters mode of invasion (P = .001), pattern (P = .01), vascular invasion (P = .02), depth (P = .006), and mean histologic score. Tobacco consumption was borderline significant (P = .055). A multivariate analysis using the Cox proportional hazard analysis showed that both clinical (stage, P < .0001; size, P = .0027), epidemiologic (tobacco consumption, P = .0054), morphohistopathologic (mode of invasion P < .0001), and stereologic (nuclear volume, P = .0010) parameters had an independent significant effect on survival. Inversely, the mean histologic score had no prognostic value. From the final regression model prognostic forecasts were calculated. Twelve patients (25%) with stage I disease had unfavorable histologic and stereologic parameters. The observed survival (+/- 1 standard error of the estimate) for these patients was 33% +/- 18%. The observed survival for stage I patients with more favorable histologic and stereologic characteristics (n = 36) was 76% +/- 8%.

CONCLUSION

The use of a combination of clinical, histologic, epidemiologic, and stereologic parameters will assist the design of treatment strategies for intraoral SCC.

DNA ploidy in nonmelanoma skin cancer

BACKGROUND

Patients with head and neck squamous cell carcinoma die of locoregional recurrence and those with basal cell carcinoma suffer cosmetic and functional changes from its treatment. Prognostic factors are based upon tumor characteristics and host factors. Flow cytometry can assist with prognostic characterization of nonmelanoma skin cancer.

METHODS

Specimens from 40 sequential patients with head and neck nonmelanoma skin cancers were prospectively obtained at the time of surgery. The patients were followed for four years for local recurrence and metastasis to regional lymph nodes. Samples were prepared from frozen specimens using a modification of the Vindelov procedure.

RESULTS

DNA aneuploidy or tetraploidy and histology of well differentiated squamous cell carcinoma were significantly associated with metastasis to regional lymph nodes. Direct extension of tumor below the adipose tissue was associated with an S-phase greater than 4.1 and a proliferative fraction greater than 5.5. No tumors recurred at the site of surgical resection.

CONCLUSIONS

The measurement of DNA ploidy of well differentiated squamous cell carcinoma, and proliferative capacity or S-phase of both basal cell and squamous cell carcinomas assists in predicting the biologic proclivity for locoregional invasion or metastasis of nonmelanoma skin cancer. Identification of aggressive tumors at the time of surgery may offer the opportunity for prevention of lethal metastasis by using adjunctive therapy.

Feulgen hydrolysis profiles and acid-labile DNA in oral squamous cell carcinoma

The full Feulgen hydrolysis profiles of healthy and malignant oral epithelial cells were compared by measuring the staining density of nuclei using microdensitometry after varying hydrolysis times. Malignant nuclei contained significantly increased levels of acid-labile DNA. The relative amounts of the rapidly hydrolysable fraction were compared after 5 min hydrolysis for exfoliating epithelial cells from healthy oral mucosa, healing chronic ulcers and squamous cell carcinomas. Although the latter exhibited a wide range of values, analysis of variance showed significant differences (P < 0.05) between healthy control and ulcer groups compared to oral carcinoma. The relative proportion of highly acid-labile DNA in malignant nuclei showed a significant positive correlation with mitotic score (P < 0.01) but no significant correlation with nuclear area. It was concluded that since the susceptibility of DNA to acid hydrolysis probably reflects functional differences in nuclear activity between cells, estimation of the highly acid-labile fraction may have diagnostic and/or prognostic value.

The significance of PCNA and p53 protein in some oral tumors

The expression of PCNA and p53 protein was evaluated in a total of 75 cases of benign and malignant lesions of the oral cavity, comprising 50 squamous cell carcinomas (SCCs), 14 leukoplakias, and 11 pleomorphic adenomas. The DNA histogram of 20 SCCs was measured by flow cytometry. p53-positive cells were frequently seen in SCCs, but were rare in leukoplakias and pleomorphic adenomas. The PCNA labeling index (LI) was higher in SCCs than in other benign lesions. The expression rate of p53 protein was markedly elevated in SCCs obtained from smoking patients, when compared to nonsmoking patients. DNA ploidy did not show a close relationship with PCNA and p53 expression. The mean value of PCNA LI for 22 cases carrying positive p53 protein was 52.3%, which was higher than that of p53 protein negative cases (35.7%). The Kaplan-Meier survival curve of the patients who were negative for p53 was significantly more favorable than for patients who were positive for p53 (P < 0.01, Cox-Mantel test). These results suggest that PCNA and p53 LI are markers for the malignant potential of the oral mucosa, and are a useful indicator suggesting a poor prognosis.

Expression of matrix metalloproteinase-3 in stage I and II squamous cell carcinoma of the oral cavity

PURPOSE

The object of this study was to evaluate the significance of matrix metalloproteinase-3 (MMP-3) in tumor invasion and metastasis of early squamous cell carcinoma (SCC) of the oral cavity.

MATERIALS AND METHODS

Surgical specimens from 65 patients with stage I and II SCC of the oral cavity were the subjects of this study. Tissue specimens were fixed in formalin and embedded in paraffin, and the sections were stained with monospecific antibodies against human MMP-3 by the avidin-biotin-peroxidase complex method.

RESULTS

Of the 65 patients, 30 (46.2%) tested positive for MMP-3. Immunoreactivity revealed the expression of MMP-3 to be in the small cancer nests in the advancing front of invasion, but not in normal oral epithelium. MMP-3 expression was positively correlated with tumor size, depth of tumor invasion, diffuse invasive mode, and the high incidence of lymph node metastasis.

CONCLUSION

MMP-3-containing tumors will invade adjacent normal tissues more aggressively, including lymphatic and blood vessels. Therefore, the examination of MMP-3 expression in biopsy specimens should provide information useful in predicting the malignant potential of early SCC of the oral cavity.

Flow cytometric DNA analysis of classic and steroid-induced Kaposi's sarcoma

Flow cytometric DNA analysis of various tumours has indicated a correlation between the degree of malignancy and ploidy; results which could have clinical significance. We analysed the ploidy of Kaposi's sarcoma (KS) tumours, and classified the results according to clinical history and histological findings. We found that patients on steroid treatment had an aneuploid pattern, and most of the patients with classic-type KS had a diploid pattern on flow cytometry.

Lack of correlation between DNA ploidy, Langerhans cell population and grading in oral squamous cell carcinoma

This study was undertaken to determine the inter-observer reproducibility of the invasive cell grading method on oral squamous cell carcinomas and to correlate this with the DNA ploidy status and Langerhans cell (LC) population. Fifty formalin-fixed paraffin-embedded blocks that contained both tumor and adjacent normal epithelium were randomly selected. DNA ploidy analysis was performed on a flow cytometer and the LC population was determined using an immunohistochemical technique with anti-S100 and anti-HLADR primary antibodies. The inter-observer correlation of the total malignancy score and individual morphologic features was highly significant. Thirty-two of the 50 tumors were graded as poorly differentiated and 18/50 as moderately differentiated. Thirteen of 25 poorly differentiated tumors had an aneuploid DNA content compared with 9/18 of the moderately differentiated group. No statistical differences in the LC counts between the poorly and moderately differentiated and aneuploid and diploid carcinomas were found. This study showed that the invasive cell grading method is reproducible but no correlation was found between the grading results and the ploidy status or LC count.

Influence of cisplatinum and 5-fluorouracil on the oral mucosa

In a prospective study we examined the effect of preoperative chemotherapy with cisplatinum and 5-fluorouracil (5FU) in 40 patients with a carcinoma of the oral cavity. Histopathological grading, cell kinetic and immuno-histochemical parameters of the mucosa were determined at two different locations. Prior to therapy histological dysplasias "close" to the tumour were observed in the mucosa of 75% of the patients. Dysplastic changes of the mucosa "far" from the tumour were also found in more than one third of the patients. Our results show that more advanced dysplasias improve under the influence of preoperative systemic chemotherapy only temporarily. Moreover, new dysplasias which appeared during chemotherapy and persisted after its termination are probably induced.

Flow cytometric analysis of DNA content in squamous carcinoma of the tongue: the relationship to host and tumour factors and survival

Cellular DNA content has been found to be an important prognostic factor in many human tumours, yet within the head and neck region few studies have examined its effect on survival and in those that have, findings differ. Eighty-one consecutive patients with squamous carcinoma of the tongue mainly treated by surgery and post-operative radiotherapy were studied. The DNA content of archival paraffin embedded tumours was measured by flow cytometry. Fifty-seven tumours were diploid and 24 were aneuploid. There was no association between ploidy status and age, sex, tumour size or nodal status. Ploidy status was not related to survival. These findings indicate that analysis of tumour DNA content in squamous carcinoma of the tongue does not provide any additional prognostic information for the individual patient.

Evidence for a pathway independent from 2'-deoxyguanosine and reversible by IL-2 by which purine nucleoside phosphorylase inhibitors block T-cell proliferation

Patients with homozygous deficiency of purine nucleoside phosphorylase (PNP) present with a T-cell selective immune deficiency. To elucidate the potential use of PNP inhibitors in the therapy of cutaneous T-cell lymphomas (CTCLs) the authors studied the effects of CI-1000 (formerly PD141955-2) and CI-972 on a T-cell line MyLa established from a patient with mycosis fungoides. Both PNP inhibitors had significant, dose-dependent, inhibitory effects on the proliferation of the T-cell line. CI-1000 (ED50: 3.7 microM) was approximately six-fold more potent in blocking 3H-thymidine uptake than CI-972 (ED50: 22.5 microM). The inhibitory effect of either substance could not be increased by addition of deoxyguanosine. Flow cytometric analysis revealed that both PNP inhibitors caused a block in the S-phase of the cell cycle. The inhibitory effect on proliferation was reversible partially by addition of IL-2. When testing proliferation inhibition of both substances on an IL-2-dependent T-cell line (SeAx), their inhibitory effects were reduced significantly. These data document a mechanism of action of the PNP inhibitors independent of deoxyguanosine and partially reversible by IL-2. The authors' observations suggest the potential use of PNP inhibitors in the therapy of cutaneous T-cell lymphomas and provide evidence for a pathway independent from deoxyguanosine by which PNP inhibitors might function in T cells.

Flow cytometric analysis of nuclear DNA content in tongue squamous cell carcinoma: relation to cervical lymph node metastasis

The relationship between DNA ploidy and the incidence of cervical lymph node metastasis in 36 patients with tongue squamous cell carcinoma (SCC) was investigated. The aneuploidy rate of tongue carcinomas was 15/36 (42%), and the mean DNA index (DI) was 1.23, with a range from 0.87 to 3.54. Histologically identified cervical lymph node metastasis was observed in 11 cases, and the incidence of the cervical lymph node metastasis was significantly (P < 0.02) higher in the aneuploid cases (8/15) than in the diploid cases (3/21). Recurrence of the primary lesions was seen in nine cases 0.3-2.5 years after the initial treatment. No obvious difference in the incidence of the recurrence was noted, however, between the diploid (5/21) and the aneuploid (4/15) cases. These results indicate a significant relationship between aneuploidy and incidence of the regional lymph node metastasis, in contrast to the absence of a positive relationship between aneuploidy and recurrence of tongue SCC.

Potential doubling time in head and neck tumors treated by primary radiotherapy: preliminary evidence for a prognostic significance in local control

PURPOSE

The aim of the study was to determine preliminarily whether cell kinetic parameters evaluated using in vivo infusion of bromodeoxyuridine (BrdUrd) and flow cytometry, play a role as prognostic factors of loco-regional control in squamous cell head and neck carcinoma treated with radiotherapy.

METHODS AND MATERIALS

Between April 1989 and December 1991, 42 patients with unresectable Stage II-IV squamous cell carcinoma of the oral cavity, pharynx or larynx were given an infusion of BrdUrd solution prior to primary tumor biopsy sampling at 4-6 hr later. The simultaneous labeling S-phase fraction (LI) and duration (Ts) as well as the estimated potential doubling time (Tpot) were measured using flow cytometric analysis of BrdUrd and DNA content. Twenty-six patients received standard radiotherapy (70 Gy/35 fractions/7 weeks) whereas 15 patients were treated with the concomitant boost technique (75 Gy/40 fractions/6 weeks).

RESULTS

A complete set of flow cytometric data was available for 31 patients. The median value of LI, Ts, and Tpot were 9%, 9 hr and 5 days, respectively. Univariate analysis among the patients treated homogeneously by standard radiotherapy, indicated that local control was affected by Tpot value (p = 0.02). When the same analysis was performed for the patients treated with either standard radiotherapy or concomitant boost regimen, we found a p = 0.04. Thus, patients with a tumor Tpot value < or = 5 days had a significantly lower three-year local control than patients with Tpot > 5 days. Log-rank test univariate analysis showed, in addition, that nodal status was the strongest prognostic factor of local control (p = 0.005). Age, tumor stage, tumor site, performance status, grading, radiotherapy regimen, DNA ploidy and LI value were, instead, not significantly related to loco-regional control. Finally, when comparing the type of radiotherapy for tumors with Tpot < or = 5 days, we found a trend toward a better local control after concomitant boost regimen, with respect to standard regimen (p = 0.06).

CONCLUSION

The present preliminary results suggest that Tpot could play a role as additional prognostic factor influencing the disease outcome in head and neck carcinoma treated by radiotherapy.

The behaviour of neurogenic tumours of the maxillofacial region

In 37 patients with neurogenic tumours of the maxillofacial region, epidemiology, clinical, sonographical and computer tomographical findings as well as the results of fine needle aspiration cytology (FNAC), histopathological evaluation of biopsies and flow cytometric determination of DNA ploidy, were analyzed in order to detect characteristics distinguishing the behaviour of the neoplasm prior to resection. Simultaneous histopathological and flow cytometric evaluation of biopsies is recommended to avoid the danger of mistaking ancient schwannomas for malignancies and vice versa. FNAC proved to be unreliable in these cases. The retromaxillary/pterygomandibular region appeared to be the most likely site for malignant schwannoma. Von Recklinghausen's neurofibromatosis in the patient or in their family should lead to immediate investigation of any mass developing in the vicinity of the facial or trigeminal nerves.

Tissue markers of potentially malignant human oral epithelial lesions

Tissue markers of potential malignancy have been sought for many years. Cell surface markers, particularly blood group and histocompatibility antigens, have shown great promise and several squamous carcinoma antigens have been identified--but not fully studied in potentially malignant lesions. Growth factors and receptors also need further study. Cytoplasmic markers of potential malignancy have been examined and, of these, keratins, filaggrin, and some carcinoma antigens show most promise. Nuclear analyses have promise but are time-consuming and expensive. Image cytometric analyses appear to be sensitive and predictive: oncogene and tumour suppressor analyses remain to be fully evaluated. New investigative techniques at the cellular and molecular level show increasing promise at defining potentially malignant oral epithelial lesions but more prospective studies are required.

DNA ploidy analysis of squamous cell head and neck cancer to identify distant metastasis from second primary

We conducted an investigation by flow cytometry to determine whether lung cancer in eight patients with oral cancer represented a metastasis or a second primary. One patient had the same aneuploid cell population at both sites which indicated the lung lesion to be a metastasis. Two patients had a diploid lesion at both sites. In these patients, a second primary could not be distinguished from a distant metastasis because (notwithstanding both lesions being diploid) the tumors may have a different DNA content but at a level too low for flow cytometric detection. Five cases had differing DNA indices, which could represent a second primary as well as the emergence of a new clone during tumor progression and metastasis. It appears that DNA flow cytometry can identify tumors that are the same if both have the same aneuploid pattern, but it cannot prove that they are different.

Diagnostic significance of nuclear DNA content and nuclear area in oral hyperplasia, dysplasia, and carcinoma

The nuclear DNA content and the nuclear area in hyperplasia, dysplasia, and carcinoma of the oral cavity were quantitatively analyzed by microspectrophotometry. In carcinoma, marked variability of the nuclear DNA content and the nuclear area was found. The mean nuclear DNA content, the variance of the nuclear DNA content, the frequency of cells above tetraploid (4 C), the mean nuclear area, and the variance of nuclear area in hyperplasia and dysplasia were significantly different from these values with carcinoma. In some cases of leukoplakia and verrucous hyperplasia with subsequent malignant formation, the values were beyond the lower limit of carcinoma. The results suggest that the nuclear DNA and the nuclear area are important objective indices for predicting malignant potential of precancerous lesions.

DNA analysis of oral leukoplakia by flow cytometry

DNA ploidy of 19 oral leukoplakias with and without epithelial dysplasia was investigated and the results were compared with 11 normal gingival biopsies, 14 oral benign tumours and 50 oral squamous cell carcinomas. The results suggest a possible relationship between DNA aneuploidy and oral leukoplakias or squamous cell carcinomas, as 32% of the oral leukoplakias and 48% of the oral squamous cell carcinomas were aneuploid although all the normal gingival biopsies and the benign oral tumours examined were diploid. No significant relationship was observed, however, between DNA ploidy and epithelial dysplasia in the leukoplakias.

Prognostic value of various molecular and cellular features in oral squamous cell carcinomas: a review

Recent findings of prognostic value for oral squamous cell carcinomas (OSCCs) which may supplement clinical staging are reviewed. Many reports show that histopathologic grading, measurements of tumor-thickness and DNA-content have independent prognostic value and may thus be of clinical value. Features regarding cells at the invading margins of the tumors are probably of higher prognostic value than features within other parts of the tumors. Reportedly, various other cellular and serum markers have prognostic associations worthwhile further research.