Advanced squamous cell carcinoma of lower gingivobuccal complex: patterns of spread and failure

Bridging Tradition and Modernity: Embracing the Bipaddled Pectoralis Major Myocutaneous Flap for Challenging Oral Cavity Defects in the Free Flap Era

Oral squamous cell carcinoma is a serious global issue, with the prognosis decreasing as the disease severity increases. The implications of this condition are so disastrous that they cause a lot of suffering for the individual. Early diagnosis has proven to improve patients' overall survival and quality of life. Surgery remains the mainstay in treating oral carcinoma. It is aimed at the complete removal of the cancerous lesion along with the management of cervical nodal metastasis. Larger defects call for reconstruction with bulky flaps. In our case, we had a composite defect postresection of the cancerous lesion, which was reconstructed using a bipaddled pectoralis major myocutaneous flap.

Primary Management of Operable Locally Advanced Oral Cavity Squamous Cell Carcinoma: Current Concepts and Strategies

INTRODUCTION

Locally advanced oral cavity carcinoma (LAOCSCC) is primarily treated with surgery followed by radiotherapy with or without chemotherapy.

METHODS

A review of literature using PubMED was performed for studies reporting the management of LAOCSCC. Based on the reviewed literature and opinions of experts in the field, recommendations were made.

RESULTS

Studies have shown that outcomes following resection of T4a and infranotch (inferior to mandibular notch) T4b are comparable. We discuss the concept of compartmental resection of LAOCSCC and issues concerning the management of the neck. Further, patients who refuse or are unable to undergo surgery can be treated with chemoradiotherapy with uncertain outcomes. The role of neoadjuvant chemotherapy has shown promise for organ (mandibular) preservation in a select subset of patients.

CONCLUSION

The management strategy for LAOCSCC should be determined in a multidisciplinary setting with emphasis on tumor control, functional preservation, and quality of life of the patient.

Compartmental surgery for T4b oral squamous cell carcinoma involving the masticatory space

PURPOSE OF REVIEW

This review aims to describe the oncological outcomes of T4b oral squamous cell carcinomas (OSCC) with masticatory space involvement as well as the surgical approaches that are able to achieve compartmental 'en bloc' resection of these lesions.

RECENT FINDINGS

The masticatory space is subdivided into infra-notch and supra-notch spaces according to the axial plane passing through the mandibular notch between the coronoid process and the condyle neck. Compartmental resection for T4b OSCC with masticatory space invasion can be successfully achieved via purely external approaches or combining external and transnasal endoscopic routes. Infra-notch T4b OSCC showed survival outcomes comparable to T4a OSCC, thus prompting treatment with curative intent.

SUMMARY

Compartmental resection of the masticatory space is technically feasible with comprehensive control of tumour margins. Use of a transnasal endoscopic anterior route within a multiportal approach may provide better control of margins at the level of the pterygo-maxillary fissure. Equivalent survival outcomes between T4a and infra-notch T4b OSCC are reported. Thus, a downstaging of the latter to T4a is advisable and compartmental surgery of such advanced lesions could be considered as a first-line treatment option in selected patients.

Enbloc resection of primary oral cancer involving infratemporal fossa: A systematic "out to in and top to bottom" surgical approach and outcomes

AIM AND INTRODUCTION

The oral cavity Squamous Cell Carcinoma (OCSCC) involving infratemporal fossa (ITF) is considered as cT4b stage per AJCC 8th classification. The treatment of these group of patients is challenging due to the difficulty in achieving negative resection margin status. In this study we have highlighted our surgical technique with oncological outcome of enbloc resection of primary oral cancer involving ITF.

METHODOLOGY

- This was a single center retrospective study which included only patients with OCSCC extending into ITF. Our surgical technique of systematic "out to in and top to bottom" approach was detailed. The perioperative outcomes, histopathological details, survival outcomes were measured.

RESULTS

- Over the period of 1 year a total of 340 patients with OCSCC reported to our outpatient department, out of which 120 patients belonged to cT4 category and 32 patients were cT4b stage with involvement of ITF. Amongst 32 patients, 2 patients had distant metastasis and were excluded from the study. The 5 patients received neoadjuvant chemotherapy followed by surgery and rest all patients were taken up for upfront curative surgery. There were no significant intraoperative and postoperative complications. None of the margins were found to be involved or close in the final histopathology report. The median DFS and OS were 31 months and 27 months respectively at a median follow up of 29 months.

CONCLUSION

- Our systematic approach of enbloc resection of primary oral cancer involving ITF is safe and easily reproducible with high rate of negative resection margin status.

Invasion of the bucco-mandibular space by oral squamous cell carcinoma: histopathological analysis of invasion pattern

Background

This study aimed to determine the patterns of invasion of oral squamous cell carcinoma (OSCC) into the bucco-mandibular space (BMS) using detailed histopathological analysis and to assess clinical outcomes.

Methods

Patients with OSCC who underwent segmental mandibulectomy or hemi-mandibulectomy combined with resection of the BMS between 2012 and 2021 were included. The invasions of the BMS were classified into three patterns. Pattern A was defined as a horizontal invasion, Pattern B as a vertical invasion, and Pattern C as an expansive invasion.

Results

In total, 109 patients were reviewed. Of these 109 patients, the primary tumor affected the lower gingiva in 78 patients, the buccal mucosa in 18 patients, and was a primary intraosseous carcinoma of the mandible in 13 patients. Invasion of the BMS was significantly associated with a higher pathological T stage, positive/close margins, and lower disease-free survival (DFS) rates. The DFS rates were 86.7% and 66.0% in the BMS non-invasion and invasion groups, respectively. The DFS rates for each type of invasion were 82.1% for Pattern A, 67.4% for Pattern B, and 48.0% for Pattern C (P=0.277).

Conclusion

Patients with BMS invasion have a poorer prognosis than those without invasion of the BMS. Therefore, adjuvant therapy is necessary, especially in Patterns B and C. Evaluation of preoperative BMS invasion patterns is important for predicting the prognosis of OSCC.

Overexpression of CD73 is associated with recurrence and poor prognosis of gingivobuccal oral cancer as revealed by transcriptome and deep immune profiling of paired tumor and margin tissues

BACKGROUND

For various cancers, differences in response to treatment and subsequent survival period have been reported to be associated with variation in immune contextures.

AIM

We sought to identify whether such association exists in respect of gingivobuccal oral cancer.

MATERIALS AND METHODS

We performed deep immune profiling of tumor and margin tissues collected from 46 treatment naïve, Human Papillomavirus (HPV) negative, patients. Each patient was followed for 24 months and prognosis (recurrence/death) noted. Key findings were validated by comparing with TCGA-HNSC cohort data.

RESULTS

About 28% of patients showed poor post-treatment prognosis. These patients exhibited a high probability of recurrence even within 1 year and death within 2 years. There was restricted immune cell infiltration in tumor, but not in margin, among these patients. Reduced expression of eight immune-related genes (IRGs) (NT5E, THRA, RBP1, TLR4, ITGA6, BMPR1B, ITGAV, SSTR1) in tumor strongly predicted better quality of prognosis, both in our patient cohort and in TCGA-HNSC cohort. Tumors of patients with better prognosis were associated with (a) lower CD73+ cells with concomitant lower expression level of NT5E/CD73, (b) higher proportions of CD4+ and CD8+ T cells, B cells, NK cells, M1 macrophages, (c) higher %Granzyme+ cells, (d) higher TCR and BCR repertoire diversities. CD73 expression in tumor was associated with low CD8+ and CD4+ T cells, low immune repertoire diversity, and advanced cancer stage.

DISCUSSION AND CONCLUSION

High infiltration of anti-tumor immune cells in both tumors and margins results in good prognosis, while in patients with minimal infiltration in tumors in spite of high infiltration in margins results in poor prognosis. Targeted CD73 immune-checkpoint inhibition may improve clinical outcome.

Genome-wide DNA methylation profiling of HPV-negative leukoplakia and gingivobuccal complex cancers

BACKGROUND

Gingivobuccal complex oral squamous cell carcinoma (GBC-OSCC) is an aggressive malignancy with high mortality often preceded by premalignant lesions, including leukoplakia. Previous studies have reported genomic drivers in OSCC, but much remains to be elucidated about DNA methylation patterns across different stages of oral carcinogenesis.

RESULTS

There is a serious lack of biomarkers and clinical application of biomarkers for early detection and prognosis of gingivobuccal complex cancers. Hence, in search of novel biomarkers, we measured genome-wide DNA methylation in 22 normal oral tissues, 22 leukoplakia, and 74 GBC-OSCC tissue samples. Both leukoplakia and GBC-OSCC had distinct methylation profiles as compared to normal oral tissue samples. Aberrant DNA methylation increases during the different stages of oral carcinogenesis, from premalignant lesions to carcinoma. We identified 846 and 5111 differentially methylated promoters in leukoplakia and GBC-OSCC, respectively, with a sizable fraction shared between the two sets. Further, we identified potential biomarkers from integrative analysis in gingivobuccal complex cancers and validated them in an independent cohort. Integration of genome, epigenome, and transcriptome data revealed candidate genes with gene expression synergistically regulated by copy number and DNA methylation changes. Regularised Cox regression identified 32 genes associated with patient survival. In an independent set of samples, we validated eight genes (FAT1, GLDC, HOXB13, CST7, CYB5A, MLLT11, GHR, LY75) from the integrative analysis and 30 genes from previously published reports. Bisulfite pyrosequencing validated GLDC (P = 0.036), HOXB13 (P < 0.0001) promoter hypermethylation, and FAT1 (P < 0.0001) hypomethylation in GBC-OSCC compared to normal controls.

CONCLUSIONS

Our findings identified methylation signatures associated with leukoplakia and gingivobuccal complex cancers. The integrative analysis in GBC-OSCC identified putative biomarkers that enhance existing knowledge of oral carcinogenesis and may potentially help in risk stratification and prognosis of GBC-OSCC.

Early Combination of an Obturator with a Free Flap to Prevent Palatal Dehiscence Following Oral Cancer Surgery: Technique and Indications

Introduction

In the Indian subcontinent where tobacco chewing is rampant, composite 'bite' defects are common after oral cancer ablation, which comprise buccal mucosa, maxilla and mandible with or without skin. These are often reconstructed with soft tissue flaps like anterolateral thigh flaps, which provide ample soft tissue replacement. A common problem is palatal dehiscence where these flaps are inset, due to the dynamics of speaking and chewing, as well as the gravitational pull on the flap.

Materials and Methods

We describe our technique of combining an early custom obturator for these patients in the post operative period, which helps support the palatal inset and prevent dehiscence. We describe in detail the indications and workflow for this technique, mechanism of action and outcomes.

Results

We show the successful result of use in a single patient with an early dehiscence and how it can be incorporated into standard workflow in selected patients at risk of dehiscence.

Conclusions

This is a useful technique to prevent dehiscence in patients undergoing extensive buccal resections involving the maxilla. It allows for early oral intake and function while preventing dehiscence and dealyed wound healing, which is often costly.

Does Operable Stage IV Gingivobuccal Cancers Need Further Prognostic Subgrouping?

Background

Operable stage IV gingivobuccal complex cancer is classified as Stage IVA and IVB. Among patients with Stage IVA disease, different subgroups with likely different prognoses are combined. Patients with advanced nodal status tend to have a poorer prognosis. We divided these patients into four groups: group I (T4aN0), group II (T4aN1-2), group III (T1-3N2) constituting stage IVA category, and group IV (TanyN3) representing stage IVB. This study assesses if these patients can be prognostically subgrouped based on nodal status.

Methods

It is a prospective observational study done at a tertiary care center from July 2017 to June 2020. This study aims to analyze survival outcomes in these subgroups using Kaplan Meir, univariate and multivariate analysis.

Results

The study enrolled 113 patients of operable gingivobuccal complex stage IVA cancer with a median follow up of 26 months, disease-free survival (DFS) was 74% for group 1, while it was 55%, 26% and 32.2% for group 2, group 3 and group 4 respectively. Patients with T4N3 disease had DFS of just 15%. Patients in group 3 and 4 had the worst outcomes in terms of DFS and Overall Survival(OS) with HR-3.7 and 3.3 and 3.3 and 3.8 respectively (p value-0.001).

Conclusion

The nodal status is the most important prognostic factor affecting DFS and OS. Patients with small primary but advanced nodal stage do poorly than patients with advanced primary and node-negative disease. There is a need for subgrouping patients with Stage IVA tumors based on nodal status for better prognostication.

Prognostic factors and related complications/sequalae of squamous cell carcinoma located in the gingivobuccal complex

Background

Gingivobuccal complex (GBC) was a relatively new concept of oral subsite that was comprises of the upper and/or lower gingiva, gingival buccal sulcus, and adjacent buccal mucosa. Squamous cell carcinoma (SCC) of the GBC had a poor prognosis, with few studies analyzing this particular entity. The objective of this study was to analyze the risk factors affecting the prognosis and complications/sequalae of gingivobuccal complex cancer.

Methods

Between December 2014 and August 2019, a total of 122 patients diagnosed with primary gingivobuccal complex cancer in Beijing Stomatological Hospital, Capital Medical University were enrolled in the study. Through outpatient reviewed and telephone followed-up for 2-5 years postoperatively, postoperative relapse and complications/sequalae were assessed. The primary outcome parameter was 2-year disease-free survival.

Results

The most common central site of the tumor was the buccal mucosa (45.1%), followed by the lower gingiva (36.9%). The most diseases were pT4a (45.1%) and there was lymph node invasion (pN+) in 41.8% of patients. Moderate differentiated squamous carcinoma (77.9%) accounted for the vast majority of the histopathological differentiation. A total of 62.3% of tumors invaded the bone, while, 5.7% invaded the skin layer. Survival analysis found that 44.3% of patients experienced relapse within two years postoperatively and the mortality rate after relapse was 75.9%. Almost 60.0% of the tumors involving the maxilla and/or mandible developed relapse. Cox proportional hazards model found that pN stage (p= 0.002) and bone invasion (p= 0.007) were significant independent predictors of 2-year disease-free survival. Importantly, 63.1% of patients had postoperative (and postradiotherapy) complications/sequalae. It was noteworthy that 18 of 43 patients (41.9%) who implanted with titanium plates had hardware-related complications/sequalae, and the most of them were titanium plate exposure (61.1%).

Conclusions

Squamous cell carcinoma of the gingivobuccal complex cancer, as a new subsite worthy of attention in oral cancer, has a high complication/sequalae rate, high relapse rate and poor prognosis.

Trial registration

Prospective, Observational, Real-world Oral Malignant Tumors Study (clinicaltrials.gov identifier: NCT02395367). The approval of the Institutional Review Board of the Beijing Stomatological Hospital of Capital Medical University (Approval number: CMUSH-IRB-KJPJ-2015-08)

Outcome Analysis of Advanced Oral Cancers Requiring Large Composite Fibular Osteocutaneous Flap Reconstruction: Experience From a Tertiary Care Cancer Hospital

BACKGROUND

Advanced oral cancer entailing extensive resection of large parts of the mucosa, bone, and skin require reconstructions with composite free flaps. Our aim was to analyze the outcomes of those oral squamous cell carcinomas requiring fibular osteocutaneous free flaps with large skin defects.

METHODS

Perioperative course and histopathological and survival outcomes of 246 consecutive patients warranting composite fibular flaps from January 2010 to June 2015 at Tata Memorial Hospital, Mumbai, India, were retrospectively analyzed.

RESULTS

Despite majority of T4 disease (88.2%) and stage IV disease (92%) patients, the 5-year overall survival was 52.1% and the 5-year recurrence-free survival was 48.6% with a median follow-up of 42 months with minimal complications.

CONCLUSIONS

Reconstruction with composite fibular osteocutaneous flaps has comparable outcomes of survival with acceptable complications in mega oral squamous cell carcinomas requiring extensive resection.

The prevalence of oral squamous cell carcinoma with oral submucous fibrosis

Objective

The objective of the study was to find out the prevalence of oral squamous cell carcinoma (OSCC) with oral submucous fibrosis (OSF) in patients with OSF.

Materials and Methods

Of 48,757 patients, we found 300 OSF subjects. Three hundred patients of OSF were checked for OSCC. Both OSF and OSCC with OSF (OSCCwOSF) were diagnosed histopathologically. The prevalence of OSCCwOSF was calculated. Descriptive analysis was done. Chi-square test and t-test were calculated for proportions and mean, respectively, to check any difference among OSF and OSCCwOSF groups. Age-specific relative risk was calculated in OSF and OSCCwOSF groups. Multiple logistic regression analysis was done among odd ratios of the different variable between OSF and OSCCwOSF groups.

Results

The prevalence of OSCCwOSF among OSF was 13.7% over a period of 1 year. The mean age of OSCCwOSF group was 43.95 ± 10.22 years in comparison to the OSF group that was 35.51 ± 11.26 years (P < 0.00). The mean habit duration was significantly less in the OSF group when compared to OSCCwOSFgroup for mishri (P = 0.002). Age-specific adjusted relative risk of OSCC in OSF patient increases from 0.33 (18-34 years) to 3.86 (≥65 years).

Conclusion

It could be concluded that a 13.7% prevalence rate of OSCCwOSF in OSF patients should alert the clinician. Clinicians should, therefore, anticipate OSSC in OSF patients. This awareness could lead to the early diagnosis and management of such OSCC.

Impact of skin invasion on long-term survival outcomes in gingivobuccal complex carcinoma

INTRODUCTION

Gingivo-buccal complex cancers (GBCC) have an aggressive clinical course in the presence of skin and bone involvement.

OBJECTIVE

This study intends to analyze the clinico-pathological factors affecting local control and survival outcomes in GBCC.

METHODS

This is a retrospective study conducted on 125 GBCC cases from January 2011 to April 2016.

RESULT

Univariate analysis revealed lymphovascular invasion (LVI) and skin involvement as predictors of poor overall survival (OS) and disease- free survival (DFS). Multivariate analysis showed skin involvement and LVI to be independent prognostic factors towards poor OS. Corresponding results in case of DFS showed skin involvement to be the single most important prognostic factor. With a median follow up of 24 months, the median survival of patients with skin involvement, skin and mandible invasion and isolated mandible invasion, respectively, were 18 months, 12 months and 22 months.

CONCLUSION

GBCC with skin involvement portends poor outcome in terms of survival. In the presence of skin invasion, treatment entails liberal soft tissue and bone margin followed by adjuvant treatment.

Genes and pathways monotonically dysregulated during progression from normal through leukoplakia to gingivo-buccal oral cancer

Oral squamous cell carcinoma of the gingivo-buccal region (OSCC-GB) accounts for the highest cancer morbidity and mortality among men in India. It has been observed that about one-third of individuals with oral leukoplakia, a dysplastic precancerous lesion in the oral cavity, progress to oral cancer. We aimed to identify systematic transcriptomic changes as a normal tissue in the oral cavity progresses to frank OSCC-GB. Seventy-two OSCC-GB patients, from multiple hospitals, were recruited, and transcriptome analysis of tumor and adjacent normal tissue (of all patients) and adjacent leukoplakia tissue (of a subset of 25 unselected patients with concomitant leukoplakia) was performed. We have identified many differences in the transcriptomic profiles between OSCC-GB and squamous cell carcinoma of the head and neck regions. Compared to the normal/precancerous tissue, significant enrichment of ECM−receptor interaction, PI3K-Akt signaling, cytokine−cytokine receptor interaction, focal adhesion, and cell cycle pathways were observed in OSCC-GB. Using gene set enrichment analysis, we identified a profound role of interferon receptor signaling in tumor growth by activating immune evasion mechanisms. The role of tumor-infiltrating immune cells further supported the growth and immunosuppressive mechanism of tumor tissues. Some immune evasion genes—CD274, CD80, and IDO1—were found to be activated even in the precancerous tissue. Taken together, our findings provide a clear insight into the sequential genetic dysregulation associated with progression to oral cancer. This insight provides a window to the development of predictive biomarkers and therapeutic targets for gingivo-buccal oral cancer.

Endoscopic-assisted multi-portal compartmental resection of the masticatory space in oral cancer: Anatomical study and preliminary clinical experience

OBJECTIVES

To present an anatomical cadaver dissection study and our preliminary surgical experience with endoscopic-assisted multi-portal compartmental resection of the masticatory space (MS) in locally advanced oral squamous cell carcinoma (OSCC) of the retromolar area.

MATERIALS AND METHODS

Two fresh-frozen cadaver heads were dissected in the Laboratory of Anatomy to define the surgical steps of an endoscopic-assisted multi-portal compartmental approach to the MS. After this preclinical anatomical study, patients affected by locally advanced OSCC originating from the retromolar area with extension to the MS were prospectively enrolled and operated at two Italian referral centers for head and neck cancer between October 2019 and May 2020.

RESULTS

Surgical technique of endoscopic-assisted multi-portal compartmental resection of the MS was preclinically defined step by step in 3 phases: transnasal, transoral/trancervical, and multi-portal. Compartmental resection of the MS was successfully completed in all specimens (4 MSs dissected). The surgical technique was subsequently applied in 3 patients affected by primary OSCC of the retromolar area, providing satisfactory results in terms of negative resection margins and local control.

CONCLUSIONS

Multi-portal compartmental resection of the MS combining the transnasal and transoral/transcervical corridors is technically feasible. Such an approach to the MS in locally advanced OSCC provides different angles of incidence to the target and full control of tumor margins.

Oral Cancer in the Indian Subcontinent-Survival Outcomes and Risk Factors with Primary Surgery

OBJECTIVE

To assess the oncological outcome and prognostic factors for primary Oral Squamous Cell Cancer (OSCC) staged as per AJCC 8th pTNM, and treated by the contemporary standard of primary surgery and pathology directed adjuvant radiation-chemoradiation.

METHODS

A single institution cohort from a tertiary care academic institution in North India. Case inclusion 2013 to 2016; n = 218, median follow-up 35 months. All patients were restaged as per the AJCC 8th pTNM classification. Analysis for Overall Survival (OS), Disease-free Survival(DFS), and factors impacting outcome (Cox proportionate model Multivariate analysis).

RESULTS

AJCC pTNM 7th to 8th edition conversion led to upstaging in 16.5%. Stage-II demonstrated greatest stage migration and apparent improvement in OS and DFS (P < .09). Discordance was noted between the presurgical (clinico-radiologic) and postsurgical (pathological) nodal status in 40.3% (88/218; 54 pathologically upstaged;34 downstaged). Pathological downstaging was particularly significant with advanced stage Gingivo-Buccal Cancers (25/73-34.7%). Stage-I-II early cancers had 3 years. OS-86.7% and DFS-78.8%; Stage-III-IV advanced cancers had 3 years. OS-56.7% and DFS-46.6%. Multivariate analysis identified poorer OS and DFS for age < 40 years (HR-1.8; 2.0), skin involvement (HR-2.1; 2.6) and pN+ status (HR-2.4; 3.5). Bone involvement did not compromise survival in this surgically treated set of patients.

CONCLUSION

Age < 45 is newly identified as significantly compromising DFS and OS in Oral Cancer. Established factors of skin involvement and pN+ are confirmed as impacting DFS-OS. An apparent improvement in survival in Stage II Cancers is noted as consequent to adoption of AJCC 8th edition staging.

LEVEL OF EVIDENCE

II (OCEBM 2011-Inception Cohort Study for Prognosis) Laryngoscope, 2021.

Primary Surgical Treatment in Very Advanced (T4b) Oral Cavity Squamous Cell Carcinomas

OBJECTIVES

To describe patterns of primary surgical treatments in patients with T4b oral cavity squamous cell carcinoma (OCSCC).

STUDY DESIGN

Historical cohort study.

SETTING

National Cancer Database.

METHODS

Review of the National Cancer Database between 2004 and 2017 for all T4b OCSCCs. Only patients with curative treatment methods were included in the survival analysis. Surgical and nonsurgical outcomes were compared by multivariable and propensity score matching analysis.

RESULTS

A total of 1515 cases of T4b OCSCC were identified. A minority of patients (n = 363, 24.0%) underwent curative treatment; among these, 206 (56.7%) underwent primary surgery. Median length of follow-up was 24 months. The 90-day mortality of patients who underwent surgical treatment was 1.0%. The 2-year survival was higher for patients who underwent surgery + chemoradiotherapy (CRT) as compared with CRT (64.6% vs 45.2%, P < .001). On multivariable analysis, surgery + CRT was associated with longer survival. In a propensity score-matched cohort of 312 patients, 2-year survival remained higher in the surgical group versus the nonsurgical group (59.4% vs 45.5%, P = .02). Among patients who underwent surgery + CRT, there was no difference in 2-year survival between clinical T4a and T4b (59% vs 64.6%, P = .20).

CONCLUSIONS

A minority of patients with T4b OCSCC undergo treatments with curative intent. A subset of patients underwent primary surgical treatment, which was associated with longer survival. The T4b classification might entail a heterogenous group, and further studies in revision of this classification might be justified.

Application of Random Forest and data integration identifies three dysregulated genes and enrichment of Central Carbon Metabolism pathway in Oral Cancer

BACKGROUND

Studies of epigenomic alterations associated with diseases primarily focus on methylation profiles of promoter regions of genes, but not of other genomic regions. In our past work (Das et al. 2019) on patients suffering from gingivo-buccal oral cancer - the most prevalent form of cancer among males in India - we have also focused on promoter methylation changes and resultant impact on transcription profiles. Here, we have investigated alterations in non-promoter (gene-body) methylation profiles and have carried out an integrative analysis of gene-body methylation and transcriptomic data of oral cancer patients.

METHODS

Tumor and adjacent normal tissue samples were collected from 40 patients. Data on methylation in the non-promoter (gene-body) regions of genes and transcriptome profiles were generated and analyzed. Because of high dimensionality and highly correlated nature of these data, we have used Random Forest (RF) and other data-analytical methods.

RESULTS

Integrative analysis of non-promoter methylation and transcriptome data revealed significant methylation-driven alterations in some genes that also significantly impact on their transcription levels. These changes result in enrichment of the Central Carbon Metabolism (CCM) pathway, primarily by dysregulation of (a) NTRK3, which plays a dual role as an oncogene and a tumor suppressor; (b) SLC7A5 (LAT1) which is a transporter dedicated to essential amino acids, and is overexpressed in cancer cells to meet the increased demand for nutrients that include glucose and essential amino acids; and, (c) EGFR which has been earlier implicated in progression, recurrence, and stemness of oral cancer, but we provide evidence of epigenetic impact on overexpression of this gene for the first time.

CONCLUSIONS

In rapidly dividing cancer cells, metabolic reprogramming from normal cells takes place to enable enhanced proliferation. Here, we have identified that among oral cancer patients, genes in the CCM pathway - that plays a fundamental role in metabolic reprogramming - are significantly dysregulated because of perturbation of methylation in non-promoter regions of the genome. This result compliments our previous result that perturbation of promoter methylation results in significant changes in key genes that regulate the feedback process of DNA methylation for the maintenance of normal cell division.

Density of CD3+ and CD8+ cells in gingivo-buccal oral squamous cell carcinoma is associated with lymph node metastases and survival

The tumor immune microenvironment is emerging as a critical player in predicting cancer prognosis and response to therapies. However, the prognostic value of tumor-infiltrating immune cells in Gingivo-Buccal Oral Squamous Cell Carcinoma (GBOSCC) and their association with tumor size or lymph node metastases status require further elucidation. To study the relationship of tumor-infiltrating immune cells with tumor size (T stage) and lymph node metastases (N stages), we analyzed the density of tumor-infiltrating immune cells in archived, whole tumor resections from 94 patients. We characterized these sections by immune-histochemistry using 12 markers and enumerated tumor-infiltrating immune cells at the invasive margins (IM) and centers of tumors (CT). We observed that a higher density of CD3+ cells in the IM and CT was associated with smaller tumor size (T1-T2 stage). Fewer CD3+ cells was associated with larger tumor size (T3-T4 stage). High infiltration of CD3+and CD8+ cells in IM and CT as well as high CD4+ cell infiltrates in the IM was significantly associated with the absence of lymph node metastases. High infiltrates of CD3+ and CD8+ cells in CT was associated with significantly improved survival. Our results illustrate that the densities and spatial distribution of CD3+ and CD8+ cell infiltrates in primary GBOSCC tumors is predictive of disease progression and survival. Based on our findings, we recommend incorporating immune cell quantification in the TNM classification and routine histopathology reporting of GBOSCC. Immune cell quantification in CT and IM may help predict the efficacy of future therapies.

Marginal Mandibulectomy Defect Reconstruction with Pectoralis Major Myocutaneous (PMMC) Flap in Cases of Carcinoma Buccal Mucosa: Experience from a Tertiary Cancer Institute

Patients with carcinoma buccal mucosa requiring marginal mandibulectomy pose various key challenges with regard to reconstruction. To study the role and feasibility of the PMMC flap reconstruction in patients of carcinoma buccal mucosa with intact mandible. Study design: retrospective analysis of prospectively maintained data at a tertiary cancer institute in India. Inclusion criteria: all patients of carcinoma buccal mucosa undergoing marginal mandibulectomy at our institute from 1st Jan 2015 to 31st March 2018 with reconstruction done by the PMMC flap. The retrospective analysis showed 82 patients satisfied the inclusion criteria. Median age of the patients was 46 years. Seventy-seven (93.90%) patients were male while 5 (6.09%) patients were female. Median Ryle's tube dependency was 13 days. Median follow-up period was 28 months. All the patients had acceptable cosmesis and mouth opening with minimal morbidity. PMMC flap reconstruction after marginal mandibulectomy in patients with carcinoma buccal mucosa is a robust, cosmetically, and functionally acceptable option.

Compartmental Clearance of Infratemporal Fossa for T4b Carcinoma of Buccal Mucosa/Alveolus: Clinical Outcomes

T4 b carcinoma of oral cavity has poor outcomes. The aim for analysis is to evaluate the clinical outcomes with infratemporal fossa clearance for stage T4b carcinoma of oral cavity. Fifty four patients out of maintained data of 528 patients of oral cavity carcinoma were evaluated for current retrospective analysis. All had T4b disease on imaging and underwent bite composite resection with ITF clearance. The median age of the cohort was 52 years. At last follow-up, 28 patients were alive. Twenty two patients had loco-regional recurrence (ITF recurrence 7), and 16 patients had distant metastasis. At median follow-up of 29 months, 2-year loco-regional control, DFS and OS were 52%, 54% and 54%, respectively. Perineural invasion, pathological tumour stage, node positive and ITF tissue involvement were associated with poor oncological outcomes. ITF clearance is feasible in clinical practice and provides curative option for this group.

Myeloid-derived suppressor cells impede T cell functionality and promote Th17 differentiation in oral squamous cell carcinoma

Oral tumor microenvironment is characterized by chronic inflammation signified with infiltrating leukocytes and soluble mediators which cause immune suppression. However, how immunosuppressive cells like myeloid-derived suppressor cells (MDSCs) maintain the immunosuppressive tumor microenvironment and influence T cell function in oral squamous cell carcinoma (OSCC) patients remains poorly understood. In the present study, we found that percentages of MDSCs were higher in oral cancer patients compared to healthy individuals and correlated with cancer stage. Monocytic MDSCs (M-MDSCs) were prevalent in the periphery, while granulocytic/polymorphonuclear subset dominated the tumor compartment. M-MDSCs suppressed the lymphocyte proliferation and decreased the CD3-ζ (zeta) chain expression and interferon gamma production. The percentage of M-MDSCs in peripheral blood correlated inversely with CD3-ζ chain expression in T cells of these patients. Interleukin 6 (IL-6)-induced phosphorylated STAT3-regulated programmed cell death ligand 1, CCAAT/enhancer-binding proteins alpha and beta and Interleukin 10 expression in MDSCs. MDSCs inhibited TGF-β-driven generation of induced regulatory T cells in vitro. M-MDSCs secreted interleukins IL-6, IL-1β, IL-23 and PGE2 and facilitated T-helper 17 (Th17) cell differentiation which utilizes nitric oxide synthase and cyclooxygenase 2 enzyme activity. Interestingly, OSCC patients showed increased levels of Th17 cells in peripheral blood and tumor tissue. Thus, increased frequency of MDSCs, Th17 cells and decreased expression of CD3-ζ chain portray T cell tolerance and chronic inflammatory state facilitating tumor growth.

Epigenomic dysregulation-mediated alterations of key biological pathways and tumor immune evasion are hallmarks of gingivo-buccal oral cancer

BACKGROUND

Gingivo-buccal oral squamous cell carcinoma (OSCC-GB) is the most common cancer among men in India and is associated with high mortality. Although OSCC-GB is known to be quite different from tongue cancer in its genomic presentation and its clinical behavior, it is treated identically as tongue cancer. Predictive markers of prognosis and therapy that are specific to OSCC-GB are, therefore, required. Although genomic drivers of OSCC-GB have been identified by whole exome and whole genome sequencing, no epigenome-wide study has been conducted in OSCC-GB; our study has filled this gap, and has discovered and validated epigenomic hallmarks of gingivobuccal oral cancer.

METHODS

We have carried out integrative analysis of epigenomic (n = 87) and transcriptomic (n = 72) profiles of paired tumor-normal tissues collected from OSCC-GB patients from India. Genome-wide DNA methylation assays and RNA-sequencing were performed on high-throughput platforms (Illumina) using a half-sample of randomly selected patients to discover significantly differentially methylated probes (DMPs), which were validated on the remaining half-sample of patients.

RESULTS

About 200 genes showed significant inverse correlation between promoter methylation and expression, of which the most significant genes included genes that act as transcription factors and genes associated with other cancer types. Novel findings of this study include identification of (a) potential immunosuppressive effect in OSCC-GB due to significant promoter hypomethylation driven upregulation of CD274 and CD80, (b) significant dysregulation by epigenetic modification of DNMT3B (upregulation) and TET1 (downregulation); and (c) known drugs that can reverse the direction of dysregulation of gene expression caused by promoter methylation.

CONCLUSIONS

In OSCC-GB patients, there are significant alterations in expression of key genes that (a) regulate normal cell division by maintenance of balanced DNA methylation and transcription process, (b) maintain normal physiological signaling (PPAR, B cell receptor) and metabolism (arachidonic acid) pathways, and (c) provide immune protection against antigens, including tumor cells. These findings indicate novel therapeutic targets, including immunotherapeutic, for treatment of OSCC-GB.

Clinicopathologic Determinants of Outcome in Pathologic T4a (pT4a) Squamous Cell Carcinoma of the Gingivobuccal Subsite of the Oral Cavity

Carcinoma of the gingivobuccal complex is one of the most common cancers in India and patients usually present in an advanced stage. There is limited data in literature regarding the factors predicting outcome in pathological T4a patients. In this study, we aimed to study the clinic-pathological factors which may influence treatment outcomes in pT4a patients. This is a retrospective study of 121 patients who underwent surgery for oral squamous cell carcinoma between August 2011 and December 2016, staged pT4a. Overall survival (OS) and disease-free survival (DFS) were analyzed for variables including age, depth of invasion, margin status, differentiation, nodal status, extranodal spread, lymphovascular and perineural spread, and adjuvant treatment. The study cohort comprised 93 males with mean age 60.28 years (S.D. 11.25). Median DFS was 21 months (range 9 to 2374 days) whereas median OS was 24.5 months (range 9 to 2374 days). On univariate analysis, lymphovascular invasion, perineural invasion, cervical nodal metastasis, and extranodal extension had a statistically significant effect on both DFS and OS. On multivariate analysis, age (p = 0.014) and adjuvant radiotherapy (p = 0.010) were the statistically significant factors affecting OS. None of the factors affected DFS on multivariate analysis. Patients staged pT4a with cervical nodal metastasis, extranodal extension, lymphovascular invasion, and perineural invasion have reduced OS and DFS. On multivariate analysis, lower age at presentation and adjuvant radiation improved patient outcome.

Role of Single-Agent Methotrexate as a Neoadjuvant Chemotherapy in Oral Cavity Cancers

Oral cancers are the most common cancer in India due to tobacco abuse in the form of chewing, smoking, and inhalation. Majority of these patients present late at advanced disease stage. Such patients have significant morbidity irrespective of the intent of treatment; the survival rate is very poor. To improve loco-regional control and survival, neoadjuvant chemotherapy has been started in many centers all over the world. To study the effect of injecting methotrexate as a single agent in (1) down-staging and increasing operability of oral cancers, (2) need for reconstructive surgery, and (3) recurrence. A total of 50 patients with biopsy-proven oral malignancy were selected over a period of 2 years from August 2014 to August 2016 for the study. Patients were subjected to weekly dose of injecting methotrexate 1 mg/kg given intravenously for 6 weeks. All patients underwent surgery after completing 6 cycles of methotrexate. A total 50 patients were started on inj. methotrexate of which 9 patients did not complete neoadjuvant chemotherapy. 53.7% of patients showed more than 50% decrease in tumor size. 29.26% of patients showed complete disappearance of cervical lymph nodes and 31.7% of patients showed more than 50% decrease in size of cervical lymph nodes. 48.78% of patients were managed with wide local excision with primary closure, decreasing the need of reconstructive surgery. 94.74% of patients did not show any recurrence in follow-up period of 1 year. Single agent methotrexate is effective in down-staging oral cancers, improving operability and decreasing morbidity and recurrence among patients.

Squamous cell carcinoma of upper alveolus: An experience of a tertiary care center of Northeast India

Objective:

The main objective of this study was to analyze the clinical behavior and the impact of nodal metastasis on the prognosis of upper alveolus squamous cell carcinoma (SCC).

Materials and Methods:

The medical records of 110 patients with SCC of the upper alveolus (International Classification of Diseases-10-C03.0) diagnosed during 2010–2015 were reviewed. Survival analysis was done using the Kaplan–Meier method and was compared using log rank-test. P < 0.05 was considered statistically significant.

Results:

Of the 110 patients, 59 were males and 51 were females. Forty-six (41.8%) patients presented with lymph node metastasis. Fifty-three (51.8%) patients presented in Stage IVA, thirty (27.3%) patients in Stage IVB, ten (9.1%) patients in Stage III, 12 (10.9%) patients in Stage II. The 5-year overall survival (OS) was 71.1% in Stage II, in Stage III it was 65.6%, in Stage it was IVA 56.7%, and in Stage IVB it was 19.4% (P = 0.02). The 5-year OS for node negative compared with node positive was 66.3% versus 37.3%, respectively (P = 0.019).

Conclusion:

Presence of lymph node metastasis is associated with lower survival rates. Adequate surgical resection with adjuvant treatment, where necessary, offers the best chance of disease control.

Harnessing genomics to improve outcomes for women with cancer in India: key priorities for research

Cumulatively, breast, cervical, ovarian, and uterine cancer account for more than 70% of cancers in women in India. Distinct differences in the clinical presentation of women with cancer suggest underlying differences in cancer biology and genetics. The peak age of onset of breast and ovarian cancer appears to be a decade earlier in India (age 45-50 years) than in high-income countries (age >60 years). Understanding these differences through research to develop diagnosis, screening, prevention, and treatment frameworks that ar e specific to the Indian population are critical and essential to improving women's health in India. Since the sequencing of the human genome in 2001, applications of advanced technologies, such as massively parallel sequencing, have transformed the understanding of the genetic and environmental drivers of cancer. How can advanced technologies be harnessed to provide health-care solutions at a scale and to a budget suitable for a country of 1·2 billion people? What research programmes are necessary to answer questions specific to India, and to build capacity for innovative solutions using these technologies? In order to answer these questions, we convened a workshop with key stakeholders to address these issues. In this Series paper, we highlight challenges in tackling the growing cancer burden in India, discuss ongoing genomics research and developments in infrastructure, and suggest key priorities for future research in cancer in India.

Nicotinic acetylcholine receptor gene polymorphism is not associated with tobacco-related oral squamous cell carcinoma

BACKGROUND

Nicotinic acetylcholine receptor is implicated in carcinogenesis indirectly through increasing nicotine dependence and directly through its impact on cell-cycle regulation. Functional polymorphism in nicotinic acetylcholine receptor alpha-5 subunit gene (CHRNA5 c.1192G>A; rs16969968) is associated with nicotine dependence and risk of lung cancer.

AIM

The aim of this study was to evaluate the association of CHRNA5 c.1192G>A polymorphism with the risk of oral squamous cell carcinoma (OSCC).

SETTINGS AND DESIGN

This was a rural teaching hospital-based case-control study.

MATERIALS AND METHODS

A total of 100 histopathologically confirmed cases of OSCC patients and 100 age- and gender-matched healthy individuals were genotyped for CHRNA5 c.1192G>A polymorphism by polymerase chain reaction-restriction fragment length polymorphism method. Allele and genotype frequencies among case and control groups were compared by Chi-squared test (Fisher's exact).

RESULTS

The frequency of CHRNA5 c.1192A allele was 22% in OSCC patients and 26% in control individuals. The difference in the distribution of alleles and genotypes between case and control groups was not significant (P > 0.05).

CONCLUSIONS

CHRNA5 c.1192G>A polymorphism is not associated with the risk of developing OSCC.

Decreased expression of cell adhesion genes in cancer stem-like cells isolated from primary oral squamous cell carcinomas

The goal of this study was to isolate cancer stem-like cells marked by high expression of CD44, a putative cancer stem cell marker, from primary oral squamous cell carcinomas and identify distinctive gene expression patterns in these cells. From 1 October 2013 to 4 September 2015, 76 stage III-IV primary oral squamous cell carcinoma of the gingivobuccal sulcus were resected. In all, 13 tumours were analysed by immunohistochemistry to visualise CD44-expressing cells. Expression of CD44 within The Cancer Genome Atlas-Head and Neck Squamous Cell Carcinoma RNA-sequencing data was also assessed. Seventy resected tumours were dissociated into single cells and stained with antibodies to CD44 as well as CD45 and CD31 (together referred as Lineage/Lin). From 45 of these, CD44+Lin- and CD44-Lin- subpopulations were successfully isolated using fluorescence-activated cell sorting, and good-quality RNA was obtained from 14 such sorted pairs. Libraries from five pairs were sequenced and the results analysed using bioinformatics tools. Reverse transcription quantitative polymerase chain reaction was performed to experimentally validate the differential expression of selected candidate genes identified from the transcriptome sequencing in the same 5 and an additional 9 tumours. CD44 was expressed on the surface of poorly differentiated tumour cells, and within the The Cancer Genome Atlas-Head and Neck Squamous Cell Carcinoma samples, its messenger RNA levels were higher in tumours compared to normal. Transcriptomics revealed that 102 genes were upregulated and 85 genes were downregulated in CD44+Lin- compared to CD44-Lin- cells in at least 3 of the 5 tumours sequenced. The upregulated genes included those involved in immune regulation, while the downregulated genes were enriched for genes involved in cell adhesion. Decreased expression of PCDH18, MGP, SPARCL1 and KRTDAP was confirmed by reverse transcription quantitative polymerase chain reaction. Lower expression of the cell-cell adhesion molecule PCDH18 correlated with poorer overall survival in the The Cancer Genome Atlas-Head and Neck Squamous Cell Carcinoma data highlighting it as a potential negative prognostic factor in this cancer.

Do we need a different staging system for tongue and gingivobuccal complex squamous cell cancers?

OBJECTIVES

To determine the need for a separate staging system for gingivobuccal complex squamous cell cancers (GBCSCC) based on 5-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) data from one institution.

PATIENTS AND METHODS

An Institutional Review Board (IRB)-approved retrospective analysis was performed on an oral cavity cancer patient database. Patients from 1985 to 2012 with primary surgical treatment for biopsy-proven squamous cell cancer (SCC) from either the oral tongue (TSCC Group) or gingivobuccal complex (GBCSCC Group), were selected as two separate subgroups. The clinicopathologic data were used to stage the patients based on the American Joint Committee on Cancer 7th edition. Survival outcomes including 5-year OS, RFS, and DSS were calculated and analyzed. A multivariate analysis was performed to identify if subsite was an independent predictor for the survival outcomes, adjusting for other variables. A p-value of less than .05 was considered statistically significant.

RESULTS

936 patients with TSCC and 486 patients with GBCSCC were considered eligible for the analysis. Patients with GBCSCC were more likely to be older (p < .001) and presented with more advanced disease (p < .001) compared to patients with TSCC. Unadjusted hazard ratio (HR) suggested GBCSCC had poor OS compared to TSCC. However, after adjusting for other variables, the adjusted HR was not significant (p = .593). There was no difference in 5-year DSS or RFS in either of the study groups.

CONCLUSION

With similar survival outcomes by stage, there is no justification for using a different staging system for GBCSCC.

The prevalence of squamous cell carcinoma in different sites of oral cavity at our Rural Health Care Centre in Loni, Maharashtra - a retrospective 10-year study

AIM OF THE STUDY

Oral cancer ranks in the top three of all cancers in India and is quickly becoming a global health priority. More than 90% of oral and oropharyngeal cancers are squamous cell carcinoma. The purpose of this study was to document its incidence depending upon the involvement of different sites of oral cavity, and its variation with age and gender.

MATERIAL AND METHODS

Histopathologically proven oral squamous cell carcinoma cases were collected from the department of oral and maxillofacial surgery RDC, PIMS. The cases were systematically grouped under three headings: anatomical sub-site of oral cavity, age group, and gender, which were analysed to calculate the prevalence of oral cancer. The study was undertaken after obtaining approval from the institutional Ethical Committee board.

RESULTS

Among the different sites of oral cavity, the highest incidence (31.47%) of oral squamous cell carcinoma was seen for buccal mucosa in our study. The most affected age group (39.50%) were patients above 50 years old, predominantly involving males.

CONCLUSIONS

The population in this study were mostly from remote areas, among which a high rate of occurrence of oral cancer was encountered because the people were of low socio-economic class, had a casual attitude towards their health, high rate of tobacco consumption, and limited health care facilities. This study provides valuable data of the prevalence of oral cancer among the rural population.

Oral squamous cell carcinoma in the background of oral submucous fibrosis is a distinct clinicopathological entity with better prognosis

BACKGROUND

The aim of this study was to compare the clinicopathological features of oral squamous cell carcinoma in the background of oral submucous fibrosis (OSCC-OSMF) and oral squamous cell carcinoma (OSCC).

METHODS

A total of 217 cases of OSCC were retrieved from achieves for the analysis. OSCC-OSMF cases were segregated on the basis of history and clinicopathological parameters.

RESULTS

The study included 217 patients of which 112 had OSCC and 105 OSCC-OSMF. OSCC-OSMFs were younger compared with OSCC. Overall oral cancer was noted predominantly in males compared to females. The number of OSCC-OSMF was more in clinical TNM stage I and stage II as compared to OSCC, whereas the number of OSCC was more in stage III and stage IV compared to OSCC-OSMF. Histological presentation of well-differentiated squamous cell carcinoma was significantly more in OSCC-OSMF compared to OSCC, whereas moderately differentiated squamous cell carcinoma was significantly more in OSCC compared to OSCC-OSMF. Regional lymph node metastasis was significantly higher in OSCC compared to OSCC-OSMF. Three-year disease-free survival rate was significantly higher in OSCC-OSMF compared to OSCC.

CONCLUSION

The OSCC-OSMF was found to be a clinicopathologically distinct entity with a better grade of tumor differentiation, less incidence of nodal metastases, and early detection (early clinical TNM stage) compared to OSCC. All these factors probably contribute to a better prognosis and increased 3-year disease-free survival in OSCC-OSMF patients.

Induction Chemotherapy in Technically Unresectable Locally Advanced T4a Oral Cavity Squamous Cell Cancers: Experience from a Regional Cancer Center of South India

Objectives:

The present study aimed to investigate the efficacy, toxicity, and impact of induction chemotherapy (IC) in technically unresectable T4a oral cavity squamous cell cancers (OSCCs).

Materials and Methods:

Patients diagnosed with technically unresectable locally advanced T4a OSCC from January 2013 and November 2016 at our center, who received 2–3 cycles of IC and then assessed for resectability, were reviewed retrospectively. Patients' profile, response rates and toxicity of IC, resectability status, and overall survival (OS) were evaluated. Statistical analyses were performed using SPSS version 17.0 for Windows (SPSS Inc., Chicago, IL, USA).

Results:

Totally 80 patients received IC, and of them 58 (72.5%) were males. Median age at diagnosis was 44 years (range, 34–62 years). All our patients received IC with doublet regimen. Majority of the patients had buccal mucosa cancers (73.8%), followed by gingivobuccal complex (21.2%) and oral tongue (5%) primaries. After IC, partial response was achieved in 17 (21.3%) patients, stable disease in 49 (61.3%) patients and disease progression was noted in 14 (17.4%) patients. Post-IC, resectability was achieved in 19 (23.8%) of 80 patients, but 4 of them did not undergo surgery due to logistic and personal reasons. The median OS of patients who underwent surgery followed by adjuvant local therapy (n = 15) was 16.9 months (95% CI: 15.2–19.8 months) and for those treated with nonsurgical local therapy (n = 65) was 8.8 months (95% CI: 6.8–10.6 months) (log-rank P = 0.000).

Conclusions:

IC had a manageable toxicity profile and achieved resectability in 23.8% of our patients with technically unresectable T4a OSCC. Patients underwent resection had a significantly better median OS than those who received nonsurgical local treatment.

Change in CD3ζ-chain expression is an independent predictor of disease status in head and neck cancer patients

CD3ζ has emerged as a clinically important immunological marker in head and neck squamous cell carcinoma (HNSCC) with reduced level of expression reported in both tumor infiltrating lymphocytes and peripheral blood lymphocytes. In this prospective study (power = 0.99, α = 0.05), CD3ζ expression was compared in 47 HNSCC patients and 53 controls using standardized flow cytometric method. There was no statistical difference in the percentages of the CD3 ε+ T-cell subset present in the peripheral blood mononuclear cells of the HNSCC patients and the healthy controls; however, T cells from the HNSCC patients produced a significantly weaker IFN-γ response in comparison to the healthy controls, when they were stimulated by the recall viral CEF peptide antigen. All patients were followed up for at least 3 years with a median follow-up of 45 months. Levels of CD3ζ-chain expression were measured at 117 follow-up visits at six-month intervals. Receiver operating characteristic curve identified the optimal cut off as a 12% increase in post treatment CD3ζ-chain expression from the baseline levels to confirm absence of HNSCC with the area under curve of 0.81 (95% CI = 0.68-0.94) for predicting absence of HNSCC. The specificity, sensitivity and positive predictive value were 81.25% 79.21% and 97.56%, respectively. Three-year disease specific survival (DSS) was significantly lower (p = 0.007) at 63.2% for patients who showed <12% increase in CD3ζ-chain level as compared to 96.2% for patients who had ≥12% increase. Our results indicate that the change in CD3ζ-chain expression from the baseline is an independent predictor of residual and recurrent HNSCC.

Neoadjuvant chemotherapy in oral cancers: Selecting the right patients

The standard of care treatment for oral squamous cell carcinoma (OSCC) at present, consist of surgical resection followed by adjuvant radiotherapy and chemotherapy as indicated. Despite recent advances the overall prognosis remains guarded. Role of neoadjuvant chemotherapy is being explored with premise of reducing extent of surgical resection, improving loco-regional control and decreasing distant metastasis, thereby improving treatment outcomes by decreasing mortality and morbidity. However, indications of neoadjuvant chemotherapy in oral cancers are not clearly defined. Majority of studies have failed to demonstrate a significant benefit of neoadjuvant chemotherapy in terms of loco regional control and overall survival in resectable OSCC. In a select subset of patients with locally very advanced and unresectable OSCC, neoadjuvant chemotherapy has been shown to cause tumor shrinkage and improve resectability. These hypothesis generating findings of reduction in distant metastasis, improved resectability and functional outcome, however need further validation. In summary, the role of neoadjuvant chemotherapy for OSCC remains investigational and has a limited role outside clinical trial.

Effectiveness of the supraomohyoid neck dissection in clinically N0 neck patients with squamous cell carcinoma of buccal mucosa and gingivobuccal sulcus

Background:

To evaluate the effectiveness of the supraomohyoid neck dissection in clinically N0 neck patients with squamous cell carcinoma of buccal mucosa and gingivobuccal sulcus.

Materials and Methods:

This was a prospective study of five patients with squamous cell carcinoma of gingivobuccal mucosa of oral cavity with clinically N0 neck, conducted over a period of 2 years from July 2007 to Oct 2009 in the Department of Oral and Maxillofacial Surgery, Narayana Dental College and Hospital. The study was conducted in patients irrespective of age, sex, size, thickness, and type of differentiation of the lesion. All patients have clinically non-palpable lymphnodes (N0 neck), while patients with palpable lymphnodes, patients with previous surgery, and patients with previous radiotherapy were excluded from the study.

Results:

Level I was the commonest site of neck metastasis in our study. Among the five patients, two (40%) patients (case 2 and 3) had occult cervical metastasis (level IB nodes are histopathologically positive nodes) and the remaining three patients (60%) had no occult cervical metastasis. The recurrence rate was 20% for patients who received postoperative radiotherapy. There was no morbidity and postoperative dysfunction and the mortality rate was only 20% in our study.

Conclusion:

Supraomohyoid neck dissection is the therapeutic procedure in clinically N0 neck patients with squamous cell carcinoma of buccal mucosa and gingivobuccal sulcus of mandible. Supraomohyoid neck dissection, when indicated, contributes to the concept of less-invasive surgery and offers functional and aesthetic advantages without compromising the clearance with minimal morbidity.

Factors predicting outcome after salvage treatment for stage IV oral squamous cell carcinoma: Evidence of the potential importance of the cyclooxygenase-2-prostaglandin E2 pathway

BACKGROUND

We determined the clinicopathological factors that predicted outcome after salvage treatment for stage IV oral squamous cell carcinoma (OSCC). Additionally, the prognostic significance of the cyclooxygenase-2 (COX-2)/microsomal prostaglandin-E synthase-1 (mPGES-1) pathway was evaluated.

METHODS

Thirty-one patients who underwent salvage surgery were included. COX-2 and mPGES-1 levels were quantified by real time polymerase chain reaction (PCR).

RESULTS

The 2-year disease-free and overall survival rates were 46% and 53%, respectively. Adequacy of initial treatment, tobacco smoking, and the presence of pathological risk factors were predictive of mortality. In patients who had not received chemotherapy before salvage surgery, high levels of intratumoral COX-2 and mPGES-1 were associated with poor prognosis. By contrast, high intratumoral COX-2 and mPGES-1 after chemotherapy were associated with improved outcomes.

CONCLUSION

Clinicopathological factors may inform treatment decisions in patients with stage IV OSCC. Expression patterns of COX-2 and mPGES-1 correlated with outcome and warrant further investigation. © 2014 Wiley Periodicals, Inc. Head Neck 37: 1142-1149, 2015.

Squamous cell carcinoma of the superior gingivobuccal sulcus: an 11-year institutional experience of 203 cases

OBJECTIVE

The report presents an 11-year Institutional experience of 203 cases with superior gingivobuccal sulcus tumours receiving surgical intervention at a comprehensive tertiary cancer care centre.

METHODS

A retrospective chart review of patients with a confirmed diagnosis of squamous cell carcinoma of superior gingivobuccal sulcus was done and data related to patient demographic profile; details of surgical procedure, follow-up and survival were collected.

RESULTS

Infratemporal fossa clearance was performed in 56 patients. The 10-year overall survival and disease-free survival was observed to be 39 and 52%, respectively, with a median follow-up of 15 months. The overall survival was 40 and 36%, respectively, in cases with and without infratemporal fossa clearance. Similarly, the disease-free survival was found to be 58 and 49%, respectively, in cases with and without infratemporal fossa clearance.

CONCLUSION

Patients with higher stage tumours who underwent infratemporal fossa clearance showed better overall and disease-free survival than those who did not undergo infratemporal fossa clearance.

Cancers of upper gingivobuccal sulcus, hard palate and maxilla: A tertiary care centre study in North India

Introduction:

Oral cancer is the sixth most common malignancy in the world, and the third most common in southeast Asia. Cancers of the upper gingivo-buccal complex are uncommon and reported infrequently. In this article, we have assessed the clinicopathological features of such cancers and their optimal management.

Materials and Methods:

We studied 64 patients with cancer of the upper gingivobuccal sulcus (GBS), hard palate, and maxilla seen between February 2009 and 2013 over a span of 4 years.

Results:

Of the 64 patients studied, 45 were male. The mean age at presentation was 50.59 years (24-80 years). Of the 64, 48 patients (75%) had a history of substance abuse in the form of tobacco chewing, smoking or alcohol. On presentation, 48 of the 64 patients (75%) had T4 disease, eight had T3, six had T2 lesion, one had T1 lesion, and 1 patient had a neck recurrence with distant metastatic disease (Tx). Out of the 64 patients, 31 had clinically palpable neck disease and two patients had distant metastatic disease. Of the 64 patients, 58 had squamous cell carcinoma, two had adenoid cystic carcinoma of the hard palate and one patient each had melanoma, sarcoma, neuroendocrine tumor, and mucoepidermoid carcinoma. Following imaging, 18 patients (28.13%) underwent upfront surgery and six following neoadjuvant chemotherapy. 14 of the 24 patients operated had simultaneous neck dissection. 2 patients with distant metastasis and 1 with cavernous sinus thrombosis received palliative chemotherapy. Out of the 64 patients, the other 24 who were inoperable were referred to radiotherapy.

Conclusion:

Upper GBS, hard palate and maxilla cancers are uncommon and are diagnosed at an advanced stage due to delay in presentation and ignorance of our population. Surgery offers the best form of treatment. NACT may be tried to downstage the disease in selected patients with borderline operable disease. However, generous margins should be taken post chemotherapy with concomitant neck dissection. Adjuvant radiotherapy is recommended in selected patients after surgery.

Post-therapeutic surveillance schedule for oral cancer: is there agreement?

INTRODUCTION

Patients with oral cavity squamous cell carcinoma represent a diverse group, and the treatment these patients undergo also varies widely. Some patients undergo local excision alone while others require extensive surgery, often with adjuvant chemoradiotherapy. The post-therapeutic surveillance schedule for these patients tends to be a "one size fits all" formula for all head and neck squamous cell carcinoma patients, which has often been dictated by institutional doctrine or a senior surgeon's dogma. The post-therapeutic needs and risks of a T1 oral cancer patient treated with surgery alone differ from those of a patient with advanced laryngeal carcinoma, and the follow-up regimen should be tailored to the specific patient's risk of loco-regional recurrence, distant metastasis, and other related medical issues.

RESOURCES AND MATERIALS

A total of 65 papers were identified, 18 of which either focused on follow-up strategy for oral cavity squamous cell carcinoma or their tabular data allowed these cases to be extracted. Internationally recognized cancer entities were also queried.

CONCLUSIONS

No international consensus was achieved about the follow-up strategies. The value of post-therapeutic surveillance schedule following oral cancer treatment is generally not in dispute, although patient-initiated symptom-driven visits can be effective in identifying tumor recurrence for oral cancer patients. The range of appointment interval schemes tends to identify a progressive escalation of visit intervals such that there are more visits in the first year than in the second, and fewer yet during the third. Patients may fail to comply with their clinic visit structure. Most references agree that follow-up beyond the third year is unnecessary and may waste medical resources as well as the time of both patient and surgeon. There is no agreement as to the need for or interval of imaging studies.