Mortality and Causes of Death After Multimodality Treatment for Advanced Oral and Oropharyngeal Cancer

Ephrin A4-ephrin receptor A10 signaling promotes cell migration and spheroid formation by upregulating NANOG expression in oral squamous cell carcinoma cells

Ephrin type-A receptor 10 (EPHA10) has been implicated as a potential target for breast and prostate cancer therapy. However, its involvement in oral squamous cell carcinoma (OSCC) remains unclear. We demonstrated that EPHA10 supports in vivo tumor growth and lymphatic metastasis of OSCC cells. OSCC cell migration, epithelial mesenchymal transition (EMT), and sphere formation were found to be regulated by EPHA10, and EPHA10 was found to drive expression of some EMT- and stemness-associated transcription factors. Among EPHA10 ligands, exogenous ephrin A4 (EFNA4) induced the most OSCC cell migration and sphere formation, as well as up-regulation of SNAIL, NANOG, and OCT4. These effects were abolished by extracellular signal-regulated kinase (ERK) inhibition and NANOG knockdown. Also, EPHA10 was required for EFNA4-induced cell migration, sphere formation, and expression of NANOG and OCT4 mRNA. Our microarray dataset revealed that EFNA4 mRNA expression was associated with expression of NANOG and OCT4 mRNA, and OSCC patients showing high co-expression of EFNA4 with NANOG or OCT4 mRNA demonstrated poor recurrence-free survival rates. Targeting forward signaling of the EFNA4-EPHA10 axis may be a promising therapeutic approach for oral malignancies, and the combination of EFNA4 mRNA and downstream gene expression may be a useful prognostic biomarker for OSCC.

Laminin γ2-enriched extracellular vesicles of oral squamous cell carcinoma cells enhance in vitro lymphangiogenesis via integrin α3-dependent uptake by lymphatic endothelial cells

Oral squamous cell carcinoma (OSCC) LN1-1 cells previously showed greater capacities for lymphangiogenesis and lymph node metastasis compared to their parental OEC-M1 cells, in addition to an ability to enhance the migration and tube formation of lymphatic endothelial cells (LECs). Purified by a series of differential centrifugations and characterized using electron microscopy, dynamic light scattering and western blot, LN1-1 cell-derived extracellular vesicles (LN1-1 EVs) were shown to promote LEC migration, tube formation and uptake by LECs more effectively than did OEC-M1 cell-derived EVs (OEC-M1 EVs). Using stable isotope labeling with amino acids in cell culture/liquid chromatography-tandem mass spectrometry-based proteomic platform, the laminin-332 proteins, including laminin α3, β3 and γ2, were validated as highly expressed proteins in LN1-1 EVs. Clinically, a higher level of laminin-332 was detected in plasma EVs from OSCC patients with lymph node metastasis than in both healthy controls and OSCC patients without lymphatic metastasis, suggesting EV-borne laminin-332 as a novel and noninvasive biomarker for the detection of lymph node metastasis in OSCC. The knockdown of laminin γ2 and inhibition by anti-laminin-332 neutralizing antibodies impaired LN1-1 EV-mediated LEC migration, tube formation and uptake by LECs. Importantly, laminin γ2-deficient EVs showed a reduced ability to drain into lymph nodes in comparison with the control EVs. In addition, the laminin 332/γ2-mediated EV uptake was dependent on integrin α3 but not β1, β4 or α6. Collectively, the uptake of laminin γ2-enriched EVs by LECs enhanced in vitro lymphangiogenesis and EV-borne laminin-332 is thus a viable biomarker for OSCC.

Cause-specific mortality in HPV+ and HPV- oropharyngeal cancer patients: insights from a population-based cohort

Identifying the causes of death in head and neck cancer patients can optimize follow-up and therapeutic strategies, but studies in oropharyngeal squamous cell carcinoma (OPSCC) patients stratified by HPV status are lacking. We report cause-specific mortality in a population-based cohort of patients with OPSCC. Patients who had been diagnosed with OPSCC (n = 1541) between 2000 and 2014 in eastern Denmark were included in the study. Causes of death were collected through medical files and the Danish National Cause of Death registry. Deaths were grouped as (1) primary oropharyngeal cancer, (2) secondary malignancies, (3) cardiovascular and pulmonary disease, or (4) other/unspecified. The cumulative incidence of death and specific causes of death were determined using risk analysis. At follow-up, 723 (47.5%) patients had died. The median time to and cause of death were determined: oropharyngeal cancer (n = 432; 1.00 year), secondary malignancies (n = 131; 2.37 years), cardiovascular and pulmonary causes (n = 58; 3.48 years), and unspecified causes (n = 102; 3.42 years). HPV/p16 status was the strongest predictor of improved survival across all causes of death. The only cause of death to decrease in incidence over the 2 years after treatment was death from OPSCC. HPV/p16 positivity was an independent factor for improved survival across all causes of death in patients with OPSCC. In addition, both HPV-positive and HPV-negative OPSCC patients faced high 5- and 10-year mortality rates. Implementing secondary screening and prevention strategies for late toxicity and mortality are major goals in managing the treatment of these patients.

Ataxia-telangiectasia mutated interactor regulates head and neck cancer metastasis via KRas expression

OBJECTIVES

Relapse is the most serious problem affecting the morbidity and mortality rates of patients with head and neck squamous cell carcinoma (HNSCC). Although HNSCC has been studied for several decades, the exact mechanism of cancer recurrence remains unclear.

MATERIALS AND METHODS

ataxia-telangiectasia mutated interactor (ATMIN) messenger RNA(mRNA) expression was detected in HNSCC samples by quantitative RT-PCR, and was analyzed with patients' clinical outcomes by Kaplan-Meier analyses. The ectopic ATMIN expression or ATMIN silencing on invasion ability was evaluated in HNSCC cell lines. Lymph node metastasis ability was investigated by buccal orthotopic implantation in vivo. All statistical tests were two-sided.

RESULTS

ATMIN mRNA expression was positively correlated with patients' clinical outcomes. ATMIN blockage reduced invasion, migration, and metastasis abilities both in vitro and in vivo. Evidence from a buccal orthotopic implantation mice model showed that silenced ATMIN expression prolongs mice survival and reduced lymph node metastasis. In high-throughput microarray and bioinformative analyses, KRas was identified as a crucial downstream effector in ATMIN-mediated HNSCC metastasis and was positively associated with patients' clinical stages and ATMIN mRNA expression.

CONCLUSIONS

The role of ATMIN and its regulatory mechanisms in HNSCC progression are reported for the first time. The study results improve our understanding of the ATMIN-KRas axis leading to HNSCC migration or invasion and metastasis and facilitates the identification of possible therapy targets of downstream genes for designing effective therapeutic strategies in personalized medicine.

Analysis of Survival Rates Following Primary Surgery of 178 Consecutive Patients with Oral Cancer in a Large District General Hospital

PURPOSE

The aim of this study is to present the survival rates in patients treated for oral cancer with primary surgery in a large district general hospital. We discuss the influence of the most significant prognostic factors on survival and compare our results with larger centres specializing in the management of oral cancer.

METHODS

All patients diagnosed with oral cancer from 1995 to 2006 and were treated in the Department had their details entered prospectively onto a computerized database. Demographic details of patients, type of treatment, pathological stage of tumor (TNM), local and regional recurrence rate, overall survival, disease specific survival and incidence of involved margins were recorded and calculated.

RESULTS

Of the 178 patients, 96 (54 %) were alive and free of oral cancer 5 years after surgery. Forty-four patients died of oral cancer (24.7 %) but 38 (21.3 %) died of other causes. The overall survival rate after primary surgery in relation to stage was: I 84 %, II 71 %, III 36 % and IV 28 %.

DISCUSSION

As almost half of our patients presented with advanced cancer and had discouraging survival rates, we emphasize the need for early recognition of the disease. Advanced disease signifies difficulty in obtaining clear margins which actually indicates a higher recurrence rate. 25 % of our patients died of oral cancer within 5 years of surgery which highlights the poor prognosis that recurrence carries after treatment. Effective educational campaign with purpose to raise oral cancer awareness and earlier referral may result in improvement of survival.

To evaluate disparity between clinical and pathological tumor-node-metastasis staging in oral cavity squamous cell carcinoma patients and its impact on overall survival: An institutional study

Background:

Accurate clinical staging is important for patient counseling, treatment planning, prognostication, and rational design of clinical trials. In head and neck squamous cell carcinoma, discrepancy between clinical and pathological staging has been reported.

Objective:

To evaluate any disparity between clinical and pathological tumor-node-metastasis (TNM) staging in oral cavity squamous cell carcinoma (OCSCC) patients and any impact of the same on survival.

Materials and Methods:

Retrospective chart review from year 2007 to 2013, at a tertiary care center.

Statistical Analysis:

All survival analyses were performed using SPSS for Windows version 15 (Chicago, IL, USA). Disease-free survival curves were generated using Kaplan–Meier algorithm.

Results:

One hundred and twenty-seven patients with OCSCC were analyzed. Seventy-nine (62.2%) were males and 48 (37.8%) females with a mean age at presentation 43.6 years (29–79 years). The highest congruence between clinical and pathological T-staging seen for clinical stage T1 and T4 at 76.9% and 73.4% with pathological T-stage. Similarly, the highest congruence between clinical and pathological N-stage seen for clinical N0 and N3 at 86.4% and 91.7% with pathological N-stage. Of clinically early stage patients, 67.5% remained early stage, and 32.5% were upstaged to advanced stage following pathological analysis. Of the clinically advanced stage patients, 75% remained advanced, and 25% were pathologically downstaged. This staging discrepancy did not significantly alter the survival.

Conclusion:

Some disparity exists in clinical and pathological TNM staging of OCSCC, which could affect treatment planning and survival of patients. Hence, more unified and even system of staging for the disease is required for proper decision-making.

MicroRNA-29b regulates migration in oral squamous cell carcinoma and its clinical significance

OBJECTIVES

MicroRNA (miRNA) machinery regulates cancer cell behavior, and has been implicated in patients' clinical status and prognosis. We found that microRNA-29b (miR-29b) increased significantly in advanced migratory cells. However, miR-29b controls the migration ability, and its regulatory mechanism in oral squamous cell carcinoma (OSCC) remains unknown.

MATERIALS AND METHODS

We triggered miR-29b expression in OSCC patients and cell lines by conducting real-time quantitative PCR. We determined the functions of miR-29b in the migration of OSCC cells by using gain- and loss-of-function approaches. We elevated the target genes of miR29b through software predictions and a luciferase report assay. We used an orthotopic OSCC animal model to investigate the effects of miR29b on OSCC cell metastasis in vivo.

RESULTS

The clinical data revealed that miR-29b expression was correlated with lymph node metastasis and an advanced tumor stage in 98 OSCC patients. Furthermore, multivariate analysis revealed that miR-29b expression was significantly correlated with recurrence, and indicated poor survival. MiR-29b promoted OSCC cell migration and downregulated CX3CL1, a cell-cell adhesion regulator, which plays an essential role in miR-29b-regulated OSCC cell migration machinery. Furthermore, we found that CX3CL1 expression was correlated with lymph node metastasis and an early tumor stage in OSCC patients, and negatively correlated with miR-29b expression.

CONCLUSION

MiR-29b acts as an oncomir, promoting cell migration through CX3CL1 suppression, and could be a potential therapeutic target for preventing OSCC progression.

B-cell lymphoma/leukemia 10 promotes oral cancer progression through STAT1/ATF4/S100P signaling pathway

B-cell lymphoma/leukemia 10 (BCL10) is an apoptotic regulatory protein related to advanced TNM stage and disease recurrence in oral squamous cell carcinoma (OSCC). However, the regulatory mechanism of BCL10 in OSCC progression is still unknown. Here, we showed that knockdown of endogenous BCL10 could significantly reduce cell migration and invasion abilities, retard cell proliferation by G0/G1 phase accumulation and inhibit tumorigenicity in vivo. In molecular level, we identified S100P as a crucial downstream effector of BCL10-inhibited OSCC progression by high-throughput microarray analysis. S100P messenger RNA and protein expression levels were significantly diminished in silenced-BCL10 clones, and transfected S100P expression plasmids restored migration, invasion, proliferation abilities and tumorigenicity in shBCL10 transfectants. Furthermore, we provided evidence that BCL10 regulated S100P expression through signal transducers and activators of transcription 1 (STAT1) and activating transcription factor 4 (ATF4). Knockdown of BCL10 decreased S100P promoter activity, but showed no effect in truncated STAT1/ATF4 S100P promoter.  In addition, we also found that the P50/P65 signaling pathway was involved in BCL10-enhanced OSCC progression. Restored S100P in silenced-BCL10 clones could markedly reverse P65 activation via outside-in signaling. Taken together, we discovered a novel axis of BCL10-regulated OSCC progression via STAT1/ATF4/S100P/P65 signaling, which could predict the prognosis of OSCC and will be beneficial for developing therapeutic strategy against advanced OSCC.

The impact of clinical versus pathological staging in oral cavity carcinoma--a multi-institutional analysis of survival

Objectives

To evaluate any disparity in clinical versus pathological TNM staging in oral cavity squamous cell carcinoma (OCSCC) patients and any impact of this on survival.

Design

Demographic, survival, staging, and pathologic data on all patients undergoing surgical treatment for OCSCC in Alberta between 1998 and 2006 was collected. Clinical and pathological TNM staging data were compared. Patients were stratified as pathologically downstaged, upstaged or unchanged.

Setting

Tertiary care centers in Alberta, Canada.

Main outcome measures

Survival differences between groups were analyzed using Kaplan-Meier and Cox regression models.

Results

Patients with clinically early stage tumors were pathologically upstaged in 21.9% of cases and unchanged in 78.1% of cases. Patients with clinically advanced stage tumors were pathologically downstaged in 7.9% of cases and unchanged in 92.1% of cases. Univariate and multivariate estimates of disease-specific survival showed no statistically significant differences in survival when patients were either upstaged or downstaged.

Conclusions

Some disparity exists in clinical versus pathological staging in OCSCC, however, this does not have any significant impact on disease specific survival.

Clinical outcome of reconstruction of the lateral oropharyngeal wall with an anterolateral thigh free flap

The anterolateral thigh (ALT) free flap is widely used for various reconstructions in the head and neck. However, its use in the oropharynx has not been widely evaluated, so we have reviewed our experience. We retrospectively reviewed the medical records of 28 patients with oropharyngeal cancer, who were treated with immediate reconstruction with an ALT free flap after excision. We recorded history, stage of tumour, course of operation, postoperative period, oncological treatment, clinical outcome, and follow-up. The mean age of the patients was 61 years (range 44-83). Ten of the patients had clinically relevant coexisting conditions. Most of the patients had T3-4 tumours and involved neck nodes. The operations included resection of the tumour, neck dissection, and reconstruction of the oropharynx with an ALT free flap. All donor sites were closed primarily. Eight patients (29%) developed early local complications that required reoperation. Ten patients (36%) had postoperative cardiopulmonary problems. Twenty-seven flaps succeeded; one was lost. There were no other complications or late problems of the donor site except one seroma. Twenty-one patients were given postoperative radiotherapy. After the mean follow-up period of 40 months (range 13-68) 20 patients (71%) were disease-free. Three patients required a permanent gastrostomy and one a permanent tracheostomy. We conclude that the ALT free flap can be used successfully for reconstruction of a lateral oropharyngeal defect with manageable postoperative morbidity.

Quality of life in long-term oral cancer survivors: a comparison with Spanish general population norms

PURPOSE

Health-related quality-of-life (HRQOL) data are becoming an important supplement to information pertaining to treatment outcomes for cancer patients. The purpose of this study was to evaluate the HRQOL of patients undergoing primary surgery for oral squamous cell carcinoma > or =5 years after treatment compared with the Spanish general population norms.

MATERIALS AND METHODS

A total of 50 oral cancer patients (mean age 55.78 years, 80% male) with cancer-free survival of > or =5 years after surgery were enrolled. HRQOL was assessed with a standardized questionnaire: the Medical Outcomes Study Short Form 36-Item Health Survey.

RESULTS

The Medical Outcomes Study Short Form 36-Item Health Survey scores of the oral cancer patients did not differ significantly from those of an age- and gender-matched sample from the Spanish normative population, except for the pain and social functioning domains. The patients had significantly better results compared with the population norms (Wilcoxon test, P < .05) in the physical function, general health, and vitality domains.

CONCLUSIONS

These results provide patient-reported evidence that oral cancer survivors have a similar HRQOL compared with the general Spanish population. We also believe that it would be necessary to analyze the quality of life > or =5 years after treatment or from the moment the patient was discharged.

Living with head and neck cancer and coping with dying when treatments fail

Palliative care in patients who have head and neck cancer is a complex topic that requires a multifaceted approach. The head and neck surgeon has an important duty to fulfill in managing and following the wishes of the incurable cancer patient and is obligated to direct them to the appropriate services in this challenging time.