Prognostic importance of cellular DNA content in head-and-neck squamous-cell cancers. A comparison of retrospective and prospective series

Do the Conventional Clinicopathologic Parameters Predict for Response and Survival in Head and Neck Cancer Patients Undergoing Neoadjuvant Chemotherapy?

Aims and Background

Neoadjuvant chemotherapy for head and neck carcinoma is still an important treatment modality. The prognostic value of patient and tumor parameters has been extensively evaluated in several trials, yielding mixed results. We report the prognostic factors emerging from a group of patients undergoing neoadjuvant chemotherapy.

Patients and methods

From April 1986 to June 1992, 149 consecutive patients received cisplatin-5-fluorouracil-based neoadjuvant chemotherapy. After four courses of chemotherapy, patients underwent local-regional treatment with surgery, radiation or both. A variety of patient and tumor characteristics were evaluated as predictors for response to chemotherapy and survival.

Results

The complete response, partial response and no response rates to NAC were 52%, 33% and 15%, respectively. No parameters predicted response to chemotherapy. At a maximum follow-up of 87 months, overall survival was 39% and disease-free survival was 49%. Variables shown to be predictors of survival in univariate analyses were age, performance status, histology, site, T, N, stage, and response to chemotherapy. Using the Cox regression analysis, only complete response to induction chemotherapy ( P = 0.0006), performance status ( P = 0.03), stage ( P = 0.01), age ( P = 0.03) and primary tumor site ( P = 0.04) emerged as independent prognostic factors for survival.

Conclusions

Complete response to chemotherapy was confirmed as the strongest prognostic factor influencing survival. However, conventional clinicopathologic factors did not predict response, hence, potential prognostic biologic and molecular factors for response must be sought. At present, much effort must be made for the improvement of the complete response rate, which seems to be a requisite to prolong survival.

Reduced syndecan-1 expression is correlated with the histological grade of malignancy at the deep invasive front in oral squamous cell carcinoma

BACKGROUND

Although many histopathological characteristics of oral squamous cell carcinoma (O-SCC) have been identified as prognostic factors, no factor is completely accurate and unequivocal. This study evaluated the association between the loss of syndecan-1 expression and the histological grade of malignancy at the deep invasive front in O-SCC.

METHODS

The expression of syndecan-1 at the invasive tumor front of O-SCC was examined immunohistochemically using archived tissue from 72 cases. The mean age of the patients was 62.5 years (range: 23-90 years) and the male-female ratio was 1.3:1 (41 men, 31 women). There were 26, 24, 11, and 11 cases classified as stages I-IV respectively. The correlation between the intensity of syndecan-1 immunostaining and the clinicopathological factors, especially the histological grade of malignancy at the deep invasive front (invasive front grade) was analyzed.

RESULTS

Of the 72 cases, seven (9.7%), 29 (40.3%), 36 (50.0%) showed strong, intermediate, and weak or negative syndecan-1 staining respectively. There were significant differences between syndecan-1 expression and prognosis, differentiation, and pattern of invasion at the deep invasive front. Moreover, the invasive front grade scores, based on the intensity of syndecan-1 staining, were 5.6 +/- 1.0, 8.0 +/- 2.1, and 10.2 +/- 2.3 points with strong, intermediate, and weak or negative intensity respectively; and the difference was significant (P < 0.0001). Patients with intermediate or strong intensity for syndecan-1 had significantly better prognoses than did those with negative or weak intensity (P = 0.0138).

CONCLUSION

This study demonstrated that the reduced expression of syndecan-1 seems to be a useful marker of histological malignancy at the deep tumor invasive front and may be a useful prognostic factor in O-SCC.

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.

The relationship of the histologic grade at the deep invasive front and the expression of Ki-67 antigen and p53 protein in oral squamous cell carcinoma

BACKGROUND

Although many histopathologic characteristics of oral squamous cell carcinoma (O-SCC) have been identified as prognostic factors, accurate, and unequivocal factors have not been clearly identified. The purpose of this study was to evaluate a potential association between the histologic grade of malignancy at the deep invasive front and the expression of Ki-67 antigen and p53 protein in O-SCC.

METHODS

The expression of Ki-67 antigen and p53 at the invasive tumor front area of O-SCC was examined by immunohistochemistry of archived tissue from 62 cases. The mean age of patients was 60.7 years (range: 37-89) and the male-female ratio was 1.6:1 (38 men, 24 women). There were 20, 17, 14, and 11 cases classified as stage I to stage IV, respectively. The correlation between the intensity of immunostaining for Ki-67 antigen and p53 and the histologic grade of malignancy at the deep invasive front (invasive front grade, IFG) was analyzed. The expression of Ki-67 antigen and p53 in normal oral epithelia (10 cases) was also investigated.

RESULTS

The mean Ki-67 labeling index (LI) in the O-SCC samples was 32.8 +/- 12.0% (n = 62). The mean total score of IFG (IFG score) was 9.1 +/- 2.7 points (n = 62). There was a significant linear correlation between the IFG score and the Ki-67 antigen (gamma = 0.651, R2 = 0.596, P < 0.0001). Of 50 tumors examined, 27 (54.0%) exhibited p53-positive nuclear immunostaining. The staining patterns for Ki-67 antigen and p53 were similar. Both Ki-67-LI and p53-positive status were significantly correlated with the IFG scores.

CONCLUSION

The findings of this study demonstrate that overexpression of Ki-67 antigen and p53 at the deep tumor invasive front of O-SCC is associated with histologic grade of malignancy.

Aberrant EGFR and chromosome 7 associate with outcome in laryngeal cancer

OBJECTIVES/HYPOTHESIS

Epidermal growth factor receptor (EGFR) over-expression has been reported as a prognostic indicator in laryngeal cancer; however, the association with disease outcome has been inconsistent among studies. Here, we use fluorescence in situ hybridization (FISH) in addition to immunohistochemistry to assess laryngeal squamous cell carcinoma (SCC) to determine whether FISH can better predict patient outcome.

STUDY DESIGN

Retrospective study on 59 patients presenting with advanced disease.

METHODS

EGFR and chromosome 7 genomic statuses were measured using FISH, and EGFR expression was assessed by immunohistochemistry on formalin-fixed, paraffin-embedded specimens and correlated with outcome in the 59 patients.

RESULTS

EGFR expression was marginally associated with outcome, whereas both EGFR and chromosome 7 FISH status were significantly associated with outcome, and the combination of EGFR and chromosome 7 FISH status provided the strongest association of any two combined parameters (P = .0004). Combining EGFR expression with EGFR and chromosome 7 FISH status provided further improvement (P > .0001).

CONCLUSIONS

Measurements of EGFR and chromosome 7 FISH status, and to a lesser extent EGFR expression, have potential value in treatment planning for patients with laryngeal SCC.

The high prognostic value of the histologic grade at the deep invasive front of tongue squamous cell carcinoma

BACKGROUND

Although many histopathologic factors in squamous cell carcinoma of the tongue predict the prognosis, the major predictive factors have not been identified clearly. This study analyzed the prognostic value of the histologic grade at the deep invasive front of tongue squamous cell carcinoma.

METHODS

The clinicopathologic features of 124 consecutive patients seen between January 1985 and December 1999 with previously untreated squamous cell carcinoma of the tongue were reviewed. Their mean age was 58.5 years (range: 23-90) and the male-female ratio was 1.8: 1 (79 men and 45 women). There were 41, 40, 30, and 13 cases at stage I to stage IV, respectively. The clinicopathologic factors, especially the histologic grade at the deep invasive front (invasive front grade, IFG), were analyzed to determine factors predicting prognosis.

RESULTS

The 5-year disease-free survival rate of the patients treated with curative aim only was 66.7%. Clinicopathologic factors significantly associated with the prognosis were T classification, tumor size, stage classification, tumor depth, macroscopic appearance, cervical lymph node metastasis (nodal metastasis), microvascular invasion, and IFG. In a multivariate analysis, patients with tumor depth >/=4 mm, IFG >/=8 points, and nodal metastasis had a reduced disease-free survival and IFG >/=11 points had a predictive value for nodal metastasis (odds ratio: 7.34; P = 0.0019).

CONCLUSION

This study found that a high IFG malignancy score had a high prognostic value for squamous cell carcinoma of the tongue.

Numerical aberrations of chromosomes 8, 9, 11, and 17 in squamous cell carcinoma of the pharynx and larynx: a fluorescence in situ hybridization and DNA flow cytometric analysis of 50 cases

Squamous cell carcinoma of the pharynx and larynx (SCCPL) is a genetically complex disease and is frequently associated with nonrandom chromosomal alterations. Fifty primary SCC of the pharynx (oropharynx, n=11): see and hypopharynx, n=11) and larynx ( n=28) were examined for numerical aberrations of chromosomes 8, 9, 11, and 17 with a panel of chromosome-specific repetitive DNA probes by fluorescence in situ hybridization (FISH). DNA ploidy analysis was also performed by flow cytometry (FCM). Aneusomic copy numbers of chromosomes 8, 9, 11, and 17 were discovered in 66%, 68%, 68% and 78% of tumors, respectively. FCM showed abnormal DNA content in 74% of cases (mean DNA index=1.69). Polysomy was the main finding in both DNA-aneuploid and DNA-diploid tumors (64.5% of cases). Numerical aberrations of chromosomes 8 and 11 correlated to DNA ploidy by FCM (P< 0.05). Aneusomy was present in 69.23% of DNA-diploid tumors. Marked intratumoral and intertumoral chromosomal heterogeneity was noted between individual tumors, suggesting a notable heterogeneity in aneuploid and diploid cell populations. Interphase FISH can be used to study important cytogenetic changes which occur during the development of SCC of the pharynx and larynx.

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.

DNA ploidy status as a prognostic marker and predictor of lymph node metastasis in laryngeal carcinoma

In patients with laryngeal carcinoma, nodal metastasis, recurrence after radiotherapy, and prognosis are important factors in clinical decision-making. Parameters such as tumor stage are considered insufficient for predicting these important items. The DNA ploidy status of the tumor may be a useful additional marker. The DNA ploidy status of 38 laryngeal cancers was determined by flow cytometry. Correlations were studied with TNM stage, differentiation, survival rate, relapse risk, recurrence after radiotherapy, and nodal metastasis. A positive correlation of DNA ploidy status with the development of lymph node metastases was found for diploid and peridiploid versus aneuploid tumors (DNA index, <1.4 versus > or = 1.4; p = .007). No correlation was found between ploidy status and recurrence after radiotherapy. The overall survival rate (p = .01), but not the disease-specific survival rate or the relapse risk, showed a correlation with the ploidy status. The DNA ploidy status may be a useful marker for metastatic behavior in head and neck squamous cell carcinoma and may therefore be helpful in decision-making concerning elective treatment of the neck.

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.

Proliferative capacity in head and neck cancer

BACKGROUND

Shortening of overall treatment time (accelerated radiotherapy) appears to result in an increase of the efficacy of irradiation. In this study, we compared the proliferative capacity between tumors originating in different sites of the head and neck region. Tumors with a large proliferating capacity might, theoretically, benefit most from accelerated radiotherapy.

MATERIAL AND METHODS

BrdUrd was administered intravenously in patients with head and neck carcinomas. Tumor samples were analyzed with flow cytometry. T and N stages were assessed in accordance with the TNM classification system (UICC 1987).

RESULTS

No significant differences in proliferation parameters were observed with respect to site of origin of head and neck tumors. For T3/T4 tumors, DNA ploidy is an important tumor characteristic: G1- and S-phase fractions, labeling index, and tumor doubling time Tpot differences were statistically significant; the aneuploid tumors showed the largest proliferative potential.

CONCLUSIONS

(1) In general, no significant differences in proliferation parameters were observed with respect to site of origin. (2) Aneuploid head and neck tumors have a higher proliferative capacity than diploid ones, they might benefit most from accelerated irradiation.

A review of inherited cancer syndromes and their relevance to oral squamous cell carcinoma

This paper examines the genetic defects associated with inherited cancer syndromes and their relevance to oral cancer. Tumour suppressor genes are now thought of as either gatekeepers or caretakers according to whether they control cell growth directly by inhibiting cell proliferation and/or promoting cell death (gatekeepers) or whether they maintain the integrity of the genome by DNA repair mechanisms (caretakers). In disorders such as xeroderma pigmentosum, ataxia telangiectasia, Bloom syndrome and Fanconi's anaemia, where there are defective caretaker genes, there is an increased incidence of second primary malignancies, including oral cancer. By contrast, with the exception of Li Fraumeni syndrome, abnormalities of gatekeeper genes do not predispose to oral cancer. Not only do Li Fraumeni patients develop second primary malignancies, but defects of the p53 pathway (p53 mutation, MDM2 over-expression, CDKN2A deletion) appear to be a ubiquitous feature of sporadic oral cancer as it occurs in the West. The findings suggest that genetic instability is of fundamental importance in the pathogenesis of oral cancer.

Moderate and severe endometriosis is associated with alterations in the cell cycle of granulosa cells in patients undergoing in vitro fertilization and embryo transfer

OBJECTIVE

To determine whether folliculogenesis is impaired in patients with endometriosis.

DESIGN

Prospective study.

SETTING

Yamagata University School of Medicine, Yamagata, Japan.

PATIENT(S)

Thirty women participating in an IVF program.

INTERVENTION(S)

The patients were divided into four groups according to the cause of their infertility: tubal factor (T), n = 7; male factor (M), n = 7; idiopathic (I), n = 7; and endometriosis (E), n = 9. Granulosa cells were obtained from the follicular fluid of each patient and analyzed by flow cytometry.

MAIN OUTCOME MEASURE(S)

The percentage of granulosa cells in each cell-cycle stage.

RESULT(S)

The mean (+/- SD) rate of apoptosis in the granulosa cells obtained from the patients with endometriosis was the highest among the four groups (T = 11.7% +/- 3.3%; M = 5.6% +/- 3.8%; I = 9.6% +/- 5.1%; and E = 18.6% +/- 9.6%). The percentage of S-phase granulosa cells was significantly higher in the patients with endometriosis than in all the other patients combined (E = 12.5% +/- 6%; T + M + I = 9.3% +/- 2.9%). The percentage of G2/M-phase granulosa cells was significantly lower in the endometriosis group than in the other three groups combined (E = 2.3% +/- 2.5%; T + M + I = 4.6% +/- 2.1%).

CONCLUSION(S)

Endometriosis impairs the cell cycle in granulosa cells. This phenomenon may have a detrimental effect on folliculogenesis.

High frequency of DNA aneuploidy detected by DNA flow cytometry in Bowen's disease

To detect DNA aneuploidy in Bowen's disease, we investigated DNA flow cytometric analysis. Single cell suspensions were prepared from 18 fresh samples histopathologically diagnosed as solitary Bowen's disease and analyzed by DNA flow cytometry. In 16 (89%) of 18 lesions, DNA aneuploidy was demonstrated with a single aneuploid peak. DNA indices ranged from 1.29 to 1.74. The incidence of DNA aneuploidy in Bowen's disease is higher than those of cutaneous squamous cell carcinoma, which was 25-80% in the previous reports. Therefore, in Bowen's disease. DNA aneuploidy may not imply a good marker for characteristics of non-melanoma skin cancer. A single aneuploid peak commonly observed in Bowen's disease suggests that this disease consists of the monoclonal proliferation of keratinocytes containing abnormal DNA content.

Molecular markers as prognostic factors for local recurrence and radioresistance in head and neck squamous cell carcinoma

Squamous cell carcinoma of the head and neck affects more than 500,000 people worldwide each year. Local-regional recurrence of disease is a common and challenging oncological problem in patients affected by this disease. Identification of risk factors for local relapse after appropriate local therapy with surgery, radiation, or combination therapy remains an active area of clinical research. The recent development of novel molecular markers has resulted in numerous studies evaluating the prognostic significance and potential clinical utility of these markers in identifying patients at risk for local-regional relapse. This article reviews recent studies evaluating molecular markers, including p53, angiogenesis-related markers, cyclin D1, epidermal growth factor receptor, loss of heterozygosity, DNA ploidy, and cell kinetic markers. The potential clinical utility of these markers and future directions along this avenue of investigation are discussed.

Loss of heterozygosity on chromosome 2q: possibly a poor prognostic factor in head and neck cancer

BACKGROUND

Loss of heterozygosity (LOH) correlates with inactivated tumor suppressor genes. The aim of this study was to see if LOH on chromosomes 2q, 3p, 5q, 9p, and 17p correlated with survival in early squamous cell carcinoma of the head and neck (SCCHN).

METHODS

A case control study was performed. Ten patients with stage I or II tumors who ultimately died of their disease were identified and matched with suitable controls. None of the controls had a local recurrence and at time of last follow-up were alive with no evidence of disease or had died of an unrelated illness. The deoxyribonucleic acid (DNA) was extracted from paraffin blocks, and LOH studies were performed using microsatellite markers.

RESULTS

The respective incidence of allelic loss for the index and control patients was as follows: chromosome 2q, 75% and 20% (p = .03); chromosome 3p, 71% and 57%, respectively (not significant); chromosome arm 5q, 30% and 25% (not significant); chromosome arm 9p, 71% and 73% (not significant); and chromosome arm 17p, 75% and 46% (not significant). Therefore, loss on chromosome 2q strongly correlated with poor survival (odds ratio = 10.4).

CONCLUSION

Loss of heterozygosity on chromosome 2q may correlate with a poor prognosis in early-stage SCCHN.

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.

Prognostic significance of methyl-p-hydroxy-phenyllactate-esterase activity in laryngeal squamous cell carcinoma

We assayed methyl-p-hydroxyphenyllactate esterase (MeHPLAase) activity in 63 cases of primary laryngeal squamous cell carcinoma. MeHPLAase activity did not show any correlation with oestrogen, progesterone and epidermal growth factor (EGF) receptor levels. No significant relationship was found between MeHPLAase activity and age, sex, tumour site, T classification, stage of disease and EGFR status, whereas a significant inverse relationship was found between enzymatic activity and neck lymph node positivity at presentation. The median value of MeHPLAase activity tended to be higher in tumours with low histopathological grade than in those with high histopathological grade. During the follow-up period (median 50 months, range 2-90 months) locoregional recurrences were observed in 31 out of 63 (49%) cases. At the end of the study, 27 out of 63 (43%) patients had died of cancer. Cox univariate analysis using MeHPLAase activity as a continuous covariate showed that the levels of enzymatic activity were inversely associated with the risk of death and relapse. Assuming the mean value of enzymatic activity as the cut-off value, we found a statistically significant relationship between high MeHPLAase activity and longer relapse-free and overall survival. MeHPLAase activity status retained its prognostic significance also in the lymph node-negative subgroup of patients. On multivariate analysis, both EGFR and MeHPLAase activity proved to be independent factors for predicting a short relapse and the overall survival.

Interrelationships of DNA-ploidy and cell proliferation markers with T-stage and N-stage in primary laryngeal tumors

PURPOSE

The purpose of this study was to evaluate the interrelationships of DNA-ploidy and cell proliferation markers with T-stage and N-stage in primary laryngeal tumors.

METHODS AND MATERIALS

DNA-index, S-phase fraction (SPF), 5-bromo-2'-deoxy-uridine (BrdUrd)-labeling index (LI), duration of S-phase (Ts), and potential doubling time (Tpot) were determined by flow cytometry. T-stage and N-stage were assessed in accordance with the TNM classification system (UICC 1987).

RESULTS

T1-2-, when compared with T3-4-stage tumors, had significantly higher LI values (independent from N-stage) resulting in lower Tpot values. No such relationship was found with respect to N-stage. N1-3 tumors, as opposed to NO tumors, appeared to be characterized by a significantly shorter Ts (and, hence, a shorter Tpot). Ts values appeared to vary considerably (range 1.9-6.2 h). For DNA-aneuploidy, as opposed to DNA-diploidy, a significantly higher geometric mean LI was noted. Locally advanced (T3-4) tumors, when compared with T1-2 tumors, were characterized by a significantly higher percentage of DNA-aneuploidy.

CONCLUSIONS

The reported lack of prognostic relevance of cell proliferation markers to predict radiation treatment efficacy may relate to a decreased proliferative capacity (LI, Tpot) in locally advanced (T3-4) tumors, as found in our series. In laryngeal tumors, the predictive value of cell proliferation markers (LI, Tpot) should, therefore, be evaluated after stratification for T-stage. The existence of higher LI values in DNA-aneuploidy tumors was confirmed in our series, stressing the need for distinction of DNA-diploid tumor cells from DNA-diploid normal cells. The prognostic potential of DNA-index was confirmed.

Analysis of DNA ploidy using fresh frozen tissues of head and neck squamous cell carcinomas

The DNA ploidy of fresh frozen tissues of head and neck squamous cell carcinomas was determined by flow cytometry to investigate whether DNA ploidy is correlated with various clinical and pathological parameters. The subjects were 51 patients who had been treated radically by our department. The DNA ploidy pattern was classified into three types, diploid, single aneuploid and multiploid, according to the DNA index and the DNA histogram. This is our original classification. No particular correlation could be detected between the DNA ploidy pattern and sex, age, primary tumour site or disease stage. The degree of tissue differentiation tended to be poorer in aneuploid tissues than in diploid tissues. The efficacy of chemotherapy was higher in aneuploid cases than in diploid cases. The recurrence rate was significantly lower in diploid cases than in multiploid cases. When disease stage, degree of histological differentiation, efficacy of the chemotherapy and the DNA ploidy pattern were subjected to multivariate analysis for correlation with the prognosis, the DNA ploidy pattern showed the highest correlation. The results suggest that the DNA ploidy as analyzed by flow cytometry can be used as an important prognostic factor.

DNA analysis of squamous cell carcinoma in the oral cavity by image cytometry and its rating in the assessment of tumor prognosis

Image cytometric measurements on the DNA content of squamous cell carcinoma of the oral cavity were carried out to evaluate its relationship with clinicopathological features. In the prospective study 52 patients with operable oral cavity carcinoma in stage T1-4 and N0-3 were studied. The tumors were classified according to the TNM classification (UICC 1987) and graded histopathologically. A positive correlation between tumor size and ploidy status was observed. There was a significant correlation between ploidy status and histologically confirmed cervical lymph node metastases (P < 0.03). A relationship between histopathological grading and ploidy status was not found. The cumulative 5-year survival rate was significantly higher (P < 0.03) among patients with diploid DNA findings than among those with nondiploid findings. When assessing the prognosis of squamous cell carcinoma, DNA cytometry analysis should be used as an additional method. Particularly the primarily existing, significantly higher N stage, a higher frequency of metastases, and a significantly lower survival rate with nondiploid tumors underline the importance of this examination method.

Mean nuclear area and chromosomal DNA content of squamous cell carcinomas of the oral cavity using computerized image analysis

Morphometric measurements of nuclei may be of prognostic value in some cancers. In this present study we have evaluated the mean nuclear area (MNA) of 50 squamous cell carcinomas of the oral cavity (SCCOC) using computerized image analysis. Since chromosomal DNA content is a reflection of the DNA content in the nucleus, we have evaluated the relationship between MNA and chromosomal DNA. Thirteen tumours had a MNA greater than 49.9 microns2 and 37 had a MNA less than this. Six tumours were classified as hypodiploid, 29 as diploid and 15 as aneuploid. There were 44 node-negative patients and six node-positive. When comparing MNA in these groups, 50 per cent of node-positive patients had a larger MNA whilst only 20 per cent of the node-negative group had a large MNA. The correlation coefficient between MNA and DNA indices was r = 0.75. The greater nuclear size is possibly a reflection of a more aggressive tumour biology in the node-positive patients. We conclude that a large MNA may be a marker of aggressive tumour biology in this group. In the future, we aim to evaluate the prognostic significance of MNA in patients with SCCOC.

DNA ploidy and protein synthesis in squamous cell carcinoma cell lines of the head and neck

Aneuploidy as abnormal nuclear DNA content, is considered almost positive evidence of malignancy. In this study three diploid and three aneuploid squamous cell carcinoma (SCC) cell lines were examined for DNA content by flow cytometry. The DNA indices of the SCC cell lines were found to range from 1.0 to 2.1. The mitotic activity of the diploid cell lines was 1.6 times higher and the cells were smaller than aneuploid cells. To find a molecular basis for these differences, the pattern of the de-novo synthesized proteins was analyzed by means of [35S]methionine incorporation, electrophoresis, and autoradiography. In all aneuploid SCC cell lines tested in this experiment, the increase of nuclear DNA content is associated with the synthesis of a novel protein with a molecular mass of approximate 55 kDa as well as with altered synthesis rates of two preexisting proteins (50 kDa and 100 kDa). For determination of the amino acid uptake in diploid and aneuploid cells, the accumulation of [35S]methionine was measured as a function of time by liquid scintillation counting. No significant difference was found in the uptake rate between diploid and aneuploid cells with the same protein content. However, discrepancies were revealed when equal numbers of cells with different DNA index were used, suggesting, that protein turnover is different in diploid and aneuploid SCC cells.

Prognostic significance of epidermal growth factor receptor in laryngeal squamous cell carcinoma

Epidermal growth factor receptor (EGFR) content was determined by a radioligand receptor assay in 140 primary laryngeal squamous cell carcinomas (median value of 8.4 fmol mg-1 protein, range 0-169.9 fmol mg-1 protein). Cox univariate regression analysis using EGFR as a continuous variable showed that EGFR levels are directly associated with the risk of death (chi 2 = 14.56, P-value = 0.0001) and relapse (chi 2 = 7.77, P-value = 0.0053). A significant relationship between EGFR status and survival was observed at the different arbitrary cut-off values chosen (8, 16 and 20 fmol mg-1 protein). The cut-off value of 20 fmol mg-1 protein was the best prognostic discriminator. In fact, the 5 year survival was 81% for patients with EGFR- tumours compared with 25% for patients with EGFR+ tumours (P < 0.0001). The 5 year relapse-free survival was 77% for patients with EGFR- tumours compared with 24% for patients with EGFR+ tumours (P < 0.010). When clinicopathological parameters and EGFR status were examined in the multivariate analysis, T classification and EGFR status retained an independent prognostic value. In this study we demonstrated that high EGFR levels single out patients with poor prognosis in laryngeal cancer.

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.

DNA indices of primary and recurrent squamous cell carcinomas of the tongue and tonsil using image cytometry

Ploidy status of squamous cell carcinomas of the head and neck (SCCHN) from primary and recurrent tonsillar and tongue lesions has not been compared using image cytometry. We have measured and compared the DNA indices in 41 cases. There were 29 tongue SCCHN, 20/29 were primary and 9/29 were recurrent. Mean DNA index (DI) was 1.19 (range 0.70-1.81) and 1.28 (range 0.79-1.94) respectively. There were 12 tonsillar cases, 10/12 primary and two out of 12 recurrent. Mean DI was 0.84 (range 0.57-1.09) and 1.00 (range 0.98-1.02) respectively. Mean DNA indices of both primary carcinomas were lower than the mean DNA indices of the recurrent carcinomas. This difference between the two groups may be a reflection of their tumour biology. However, since our study is small no definite conclusions can be made at this stage. We aim in the future to evaluate the prognostic role of DNA indices of patients with paired primary and recurrent SCCHN. This may be of clinical value and improve the treatment modalities available to this group.

Predictive value of flow cytometric analysis in DNA contents in patients with locally advanced head and neck carcinoma

A retrospective study was performed on 61 eligible patients with stage III and IV (AJC/UICC Staging System) squamous carcinomas of the head and neck region who were treated with definitive radiotherapy with, or without, surgery. DNA contents were measured by flow cytometric analysis of archival paraffin blocks and were correlated with clinicopathological findings, tumour response and patient survival. Comparison of variables including treatment modality was performed for identification of significant prognostic factors. There were 28 diploid, 27 aneuploid tumours and the remaining six were questionable. All patients were followed-up for at least two years or until death. Aneuploid tumours had a significantly higher S-phase fraction (percentage S-phase) (p < 0.001). Neither ploidy nor percentage S-phase were found to have predictive value in tumour response or patient survival within the power of a sample size of 61. Twenty of the 27 (74 per cent) aneuploid tumours had a complete response (CR) whereas 19 out of 28 (68 per cent) diploid tumours achieved CR. Five-year survival by the Kaplan-Meier method was 33 per cent for both aneuploid and diploid tumours. However, nodal stage (N stage) was found to have significant predictive value in both tumour response and patient survival. The complete response for stage N0 patients was 96 per cent, N1 patients 61 per cent, N2 patients 60 per cent and 43 per cent for N3 patients (p < 0.002). Similarly, the five year survival for the N0 and N3 groups of patients was 53 per cent and 29 per cent respectively (p < 0.05).

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.

Relation between age and head and neck cancer recurrence after surgery: a multivariate analysis

Recent reports have described an increase in squamous cell carcinoma of the upper aerodigestive tract in young adults. As the preponderance of epidemiologic data exists for the population between 50 and 70 years of age, controversy has developed regarding the clinical course of head and neck cancer in youth. Some authors advocate more aggressive management, calling attention to the lack of "classic" predisposing factors and suggesting genetic disorders or immunodeficiency. Basic science researchers have reported greater DNA fragility, sensitivity to carcinogens, and altered immune responses in young patients with carcinoma. To further elucidate the clinical aspects of this controversy, we performed a retrospective review using multivariate analysis to determine factors that affect recurrence. After screening 820 charts, 155 patients were found who met strict entrance criteria to the study. The patients were separated into five age groups, and 16 clinical variables were collected on each patient. Cox proportional hazards modeling revealed no significantly higher likelihood of recurrence in the 15- to 39-year-old age group. The model did find that metastatic adenopathy was predictive of recurrence (p = 0.034). The overall model further suggested a trend toward higher relative risk of recurrence in the middle-aged groups (p = 0.0541). In our review of the English biomedical literature, this is the first study to directly compare the outcome of young head and neck cancer patients with that of old patients using multivariate analysis. Future research is indicated in developing precise outcome predictions according to TNM staging, aneuploidy status, and DNA fragility in young patients. Efforts at limiting carcinogen exposure should continue.

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.

DNA ploidy as a predictor of cervical metastasis in advanced squamous carcinoma of the tongue

Flow cytometric analysis of nuclear DNA content was performed in 34 squamous cell carcinomas of oral cavity and base of tongue tumours using archived paraffin-embedded tissues. The DNA content was correlated with the presence of cervical metastasis. Ten and 24 patients were classified as early (I & II) and advanced (III & IV) clinical stages, respectively. The DNA index (DI) was grouped into diploid (DI 0.85-1.15) and non-diploid. Seven (70%) tumours were non-diploid in clinical stages I & II. Four out of 7 (57%) developed initial and late cervical lymph node metastasis (p > 0.05). There were 15 (62.5%) non-diploid tumours in clinical stages III & IV. Thirteen out of 15 (86.7%) had cervical lymph node metastases (p < 0.05). However, the survival period and the incidence of recurrent disease for the whole group did not show any association with DNA ploidy. Our results suggest that DNA content may be useful as a reliable predictor of regional metastasis in advanced stage carcinoma of the tongue.

Prognostic significance of DNA ploidy in oral squamous cell carcinomas. A retrospective flow and image cytometric study with comparison of DNA ploidy in excisional biopsy specimens and resection specimens, primary, tumors, and lymph node metastases

Deoxyribonucleic acid ploidy was determined in paraffin-embedded tumor tissue from 116 patients with primary oral squamous cell carcinomas (including 5 carcinomas of the lip and 14 of the tongue) by means of flow cytometry. One hundred six cases were suitable for evaluation (91%). Sixty-eight percent of the cases (n = 72) showed a nondiploid nuclear DNA content. Nondiploidy correlated significantly with presence of lymph node metastases (p < 0.02) but not with tumor stage, grading (World Health Organization), or relapse-free and overall survival. Carcinomas of the lip and tongue turned out to be diploid more frequently than other oral squamous cell carcinomas (p = 0.002). In the 21 cases in which a comparison of DNA content of excisional biopsy specimens and subsequent resection specimens was possible a difference in DNA ploidy was found in one case only. The comparison of primary tumors and their lymph node metastases in 30 cases revealed a discrepancy of DNA content in five cases (17%), which was connected with a shift from nondiploidy to diploidy in four out of five cases. Fifty cases studied in parallel by means of image cytometry with Feulgen-stained tissue sections exhibited a concordance of the ploidy status in 87% and a significant correlation of the DNA index values obtained with both methods (p < 0.01). These results demonstrate that DNA ploidy in oral squamous cell carcinomas is distributed rather homogeneously within the tumors and remains rather stable in the lymph node metastases. Despite a significant correlation between nondiploidy and presence of lymph node metastases, ploidy failed to be a statistically significant parameter for prognosis in oral squamous cell carcinomas in our investigation.

Computer-assisted image analysis of tumor sections for a new thrombospondin receptor

BACKGROUND

A cell surface receptor (50 kd) has been recently identified in malignant cells that recognizes the tumor cell adhesive domain (ie, cysteine-serine-valine-threonine-cysteine-glycine [CSVTCG]) of thrombospondin (TSP). This CSVTCG-specific TSP receptor can be considered as a new tumor marker, and its concentration on the cell surface may correlate directly with the capacity of tumor cells to invade and metastasize.

MATERIALS AND METHODS

Six patients with primary, stages III and IV squamous cell carcinomas of the head and neck were studied. Tumor sections were specifically stained for this receptor with immunohistochemical techniques. The stained specimens were then subjected to computer-assisted image analysis. The area of positive staining and the heterogeneity of the pattern of staining were compared to peritumoral angiogenesis and clinical outcome of the patients.

RESULTS

The results indicate that those patients with a high and homogenous positive stain score (mean +/- standard error [SE] 78 +/- 5%) for the CSVTCG-specific TSP receptor had high microvessel density and died from metastatic disease within 12 months of initial treatment (correlation coefficients = 0.95 and 1, respectively). Patients with a low and heterogenous positive stain score for receptor (mean +/- SE 8 +/- 2%; P < 0.001) had low microvessel counts and remained disease-free for at least 2 years. There was no relationship between receptor density and histologic classification of the primary tumors.

CONCLUSION

The CSVTCG-specific TSP receptor, quantified through image analysis of immunohistochemical stained tissue sections, is highly predictive of clinical outcome in patients with squamous cell carcinomas of the head and neck.

Flow cytometric analysis of primary and metastatic squamous cell carcinomas of the oral and maxillofacial region

OBJECTIVE

To elucidate characteristic changes in nuclear DNA content and cell kinetics in primary lesions and metastatic lymph nodes of squamous cell carcinomas of the oral and maxillofacial region.

MATERIALS AND METHODS

Materials used were paraffin-embedded tissue specimens obtained from 96 primary lesions of 96 patients and 85 metastatic lymph nodes of 41 patients with squamous cell carcinoma of the oral and maxillofacial region. Single cell suspensions for flow cytometry analysis were prepared, and cell cycle analysis was performed.

RESULTS

The incidence of aneuploidy in 41 carcinomas with metastasis was 39%, which was significantly higher than the 16% incidence in 55 carcinomas without metastasis. In terms of T classification and mode of invasion, the incidence of aneuploidy and metastasis increased with the increase in gradings. Forty-four of 46 metastatic lymph nodes associated with 25 diploid primary tumors remained diploid, whereas a shift down to diploidy was observed in 25 of 39 metastatic lymph nodes associated with 16 aneuploid primary tumors. The incidence of aneuploidy and S-phase fractions of 85 metastatic lymph nodes in 41 patients were 19% and 9.6%, respectively. The values were significantly lower than the 39% and 14.3% of the corresponding primary lesions.

CONCLUSIONS

The chance of evolution of metastatic cell lines is higher in aneuploid carcinomas than diploid carcinomas, possibly because the former are more heterogenous; however, most cell lines responsible for causing lymph node metastasis are diploid.

Flow cytometric quantification of the proliferation-associated nuclear antigen p105 and DNA content in advanced head & neck cancers: results of RTOG 91-08

PURPOSE

p105 is a proliferation-associated nuclear antigen which identifies proliferating but not resting cells. The objectives of this Radiation Therapy Oncology Group (RTOG) protocol (91-08) were: (1) to correlate tumor proliferative potential estimated using the p105 assay and deoxyribonucleic acid (DNA) analysis with treatment outcome in patients irradiated for advanced squamous cell carcinoma of the head and neck; and (2) to evaluate the potential of p105 labeling indices as a predictive assay.

METHODS AND MATERIALS

Paraffin blocks of pretreatment biopsies of the primary tumor or metastatic neck nodes of patients with Stage III or IV squamous cell carcinoma of the head and neck treated with radiotherapy alone in three previous RTOG protocols (79-13, 79-15, and 83-13) were retrospectively obtained. From these paraffin blocks, areas of tumor were selected based on histological examinations and sectioned. Nuclei suspensions were then prepared and processed for p105 antibody and DNA staining and subsequent flow cytometric quantification of p105 labeling indices and DNA content and correlation with local-regional control and survival.

RESULTS

Paraffin blocks of tumor biopsies from 148 out of a total of 598 eligible patients were available. Of these, 143 were analyzable. The median and (range) of p105 labeling index (LI-C), p105 labeling index of cells in S phase (LI-S), and p105 antigen density (AD) were: 66.6 (3.85-99.5), 9 (1.55-36), and 93.2 (7.4-628.5), respectively. Deoxyribonucleic acid was diploid in 67 (47%), aneuploid in 22 (15%) and mixed aneuploid/diploid in 54 (38%) patients. There was a strong correlation between AD and DNA ploidy. Antigen density was above median in 91.5% of the aneuploid or mixed aneuploid/diploid tumors, but only in 8.5% of the diploid tumors. Patients with aneuploid or mixed aneuploid/diploid tumors had significantly greater local-regional failures than patients with diploid tumors (p = .0180). Those with p105 LI-C below the median or p105 AD above the median also had significantly greater local-regional failures (p = .0500 and p = .0167, respectively). Patients with p105 AD below the median had significantly better survival than those above the median (p = .0444), although there was no significant difference in survival with respect to DNA ploidy or p105 LI-C. Multivariate analyses showed that T-stage (p = .0001) and p105 AD (p = .0044) were significant prognostic factors for local-regional control, and T-stage (p = .0080), N-stage (p = .0021), primary site (p = .0110), and p105 AD (p = .0326) were significant prognostic factors for survival.

CONCLUSION

These results suggest that flow cytometric quantitation of the proliferation-associated nuclear antigen p105 and DNA content of pretreatment tumor biopsies may be a potentially useful predictive assay in patients irradiated for advanced squamous cell carcinomas of the head and neck.

Head and neck carcinoma--stage at presentation

A prospective study was performed during a 2-year-period. A total of 127 patients presenting with a squamous cell carcinoma of the head, neck and upper aerodigestive tract were entered into the study. Patients were classified according to the primary site, namely: larynx (n = 44), oropharynx (n = 28), hypopharynx (n = 17) and oral cavity (n = 19) and others (n = 19). Patients were staged according to the UICC TNM classification (1987) and the nature and duration of their symptoms were recorded. Sixty-one per cent of patients were found to be presenting with advanced disease (stages 3 and 4): oropharynx--71%; hypopharynx--77%; oral cavity--50%; larynx--34%. No relationship could be established between stage at presentation and duration of symptoms and 53% of patients with advanced disease had been symptomatic for less than 3 months at the time of diagnosis. Only 28% of patients presenting with stage 3 or 4 disease had symptoms for 3 months or longer. Earlier diagnosis will not make a significant impact on the overall prognosis in head and neck cancer.

Nuclear DNA content, proliferating-cell nuclear antigen (PCNA) and p53 immunostaining in predicting progression of laryngeal cancer in situ lesions

Squamous epithelial cancer in situ (CIS) of the upper aerodigastric tract is a histopathologically well-defined condition. However, in clinical practice, morphological grading of dysplasia is difficult and shows large variability. The biology of CIS remains enigmatic, and there is yet no reliable way to predict whether a CIS lesion will progress to invasive cancer, remain stable or regress. In the search for markers able to foretell clinical outcome, we performed image DNA cytometry (ICM) and immunohistochemical staining for PCNA as well as p53 in 38 laryngeal CIS lesions, of which 9 progressed to invasive cancer. The majority of the CIS lesions displayed high-grade DNA aberration, a high PCNA-positive rate, and every third lesion was p53-positive by immunostaining. The lesions which progressed to invasive cancer showed a clear tendency towards more pronounced DNA aberration, a higher percentage of intense PCNA staining and more frequent p53 positivity. By combining the results from the analyses of DNA, PCNA and p53 in a prognostic index for each individual case, we correctly classified 82% of the lesions as progressors or non-progressors.

Flow cytometric DNA analysis of squamous cell carcinomas of the oral cavity: correlation with clinical and histopathological features

DNA content was measured in 68 squamous cell carcinomas (SCC) of the oral cavity by flow cytometry. Samples fixed in 95% alcohol and disaggregated with 0.5% pepsin were stained with 4,6-diamidino-phenylindole (DAPI) for flow cytometry. The tumours were classified according to the TNM classification--1987, and graded histopathologically. A positive correlation between tumour size and ploidy status was observed. Poorly differentiated tumours were mainly non-diploid (P < 0.01, chi 2). A majority of the node positive (N+) tumours were non-diploid (P < 0.05). It was possible to distinguish diploid, N+, T4 tumours from diploid, N-, T4 tumours by their higher S-phase fraction (SpF). SpF was also a useful parameter to differentiate diploid, N+ tumours from diploid, N- tumours among the moderately differentiated (MD) SCC. These results suggest that ploidy and SpF can be useful correlates of tumour behaviour.

Cell kinetics of head and neck squamous cell carcinomas. Prognostic implications

Forty-three squamous cell carcinomas of the head and neck region were in vivo labelled with the thymidine analogue iododeoxyuridine. Combined flow cytometric (FCM) and immunohistochemical (IHC) analysis was performed, and the following parameters calculated: labelling index (LI), S-phase time (TS) and potential tumor doubling time (Tpot). Complete FCM and IHC analyses could successfully be performed in 31 cases, showing a median LI of 13.6% with FCM and 9.1% with IHC. A correlation achieved between LI/FCM and LI/IHC was due to the aneuploid cases, whereas the diploid cases showed no such correlation. Data indicated that Tpot calculated with LI from IHC (Tpot/IHC) might be a prognostic factor, in contrast to Tpot determined using LI/FCM.

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.

Ploidy status and the response of T1 glottic carcinoma to radiotherapy

Flow cytometric DNA ploidy measurements were performed on formalin fixed paraffin embedded tumour specimens from patients with a T1 glottic laryngeal carcinoma in order to evaluate the role of DNA content in relation to local control. From 1980 to 1987, a consecutive series of 90 patients with a T1 glottic laryngeal carcinoma were treated by radiotherapy with curative intent. Biopsies from 44 of these patients were readily available for DNA flow cytometry. In this group aneuploidy was associated with a significantly higher risk (P = 0.018) of local recurrence within 2 years after completion of radiotherapy (38% vs. 9% in the diploid group).

Proliferating cell nuclear antigen (PCNA) expression and nuclear DNA content in predicting recurrence after radiotherapy of early glottic cancer

Proliferating cell nuclear antigen (PCNA) is a DNA replication protein maximally elevated in late G1 and S phases of the cell cycle. By using monoclonal antibodies, the expression of PCNA can be quantified and the rate of tumour cell proliferation estimated. The degree of DNA aberration in a tumour cell population reflects its genetic instability and has been implicated as a prognostic factor in an increasing number of solid tumours. The nuclear DNA content can be assessed by densitometric image cytometry DNA analysis. Both PCNA and DNA analysis can be performed on histological sections from paraffin embedded biopsies. In search of efficient and reproducible methods to identify early glottic cancers with increased risk for recurrence after radiotherapy, the PCNA expression as well as the DNA content of the diagnostic biopsies from 28 T1N0M0 glottic cancers were assessed. The group of tumours which recurred locally after radiotherapy displayed lower PCNA expression and higher DNA aberration than the group of tumours which were cured. Moreover, a combination of both parameters improved the possibility to discriminate the two groups. For T1 glottic cancer displaying high grade of genetic instability or low grade of proliferation, treatment regimes other than radiotherapy and closer follow-ups could be considered.

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.

The prognostic value of cytometric DNA analysis in early stage tongue cancer

In spite of a small size and seemingly localised properties T1 tongue cancer does recur after surgical treatment, locally and/or in regional lymph-nodes, in 30-40% of the patients, and 50% of patients with recurrent disease die because of their cancer. If these patients could be identified by analysis of relevant parameters on the primary biopsy reflecting the biological properties of the tumours more extensive treatment regimes could be given selectively. In 47 primary biopsy specimens from patients with T1N0M0 squamous cell carcinoma of the mobile tongue the aberration in cellular DNA content was significantly higher in the group of tumours which recurred after surgical treatment compared with the non-recurrent group. Tumours in females recurred more frequently than in males. No significant correlation between recurrence and grade of histological differentiation or tumour thickness could be found. Image cytometry DNA analysis provides an objective and reproducible assessment of the nuclear DNA content which could facilitate selection of adequate treatment strategies.