Current surgical treatment of squamous cell carcinoma of the head and neck

Survival Outcomes and Patterns of Failure in Maxillary Alveolus Squamous Cell Carcinoma

Introduction  Squamous cell carcinoma (SCC) of the maxillary alveolus is a relatively rare disease. There is lack of data on this subsite as compared with other sites. The factors that affect survival in cases of maxillary alveolar SCC are tumor stage, local and cervical metastases, histological grading, and the margin status. Objectives  To evaluate the overall survival (OS), the disease free survival (DFS), and the complex interaction and effects of margin status, histological differentiation, habits (such as smoking and the use of smokeless tobacco products), and cervical and distant metastases based on clinicopathological data. Methods  We examined the electronic database at our hospital from 2003 to 2017. We included all cases with a histopathological diagnosis of SCC of the maxillary alveolus. Tumors originating primarily from the maxillary alveolus were included, while those originating from adjacent subsites, like the hard palate, the buccal mucosa or the maxillary sinus were excluded. We also excluded all the patients who were not operated on with a curative intent. Results  More than half of the patients had stage-IV tumors at the time of presentation, while only one fourth of them had nodal metastasis. The rate of recurrence increased in cases of primary tumors in advanced stages and the degree of histological differentiation. The 2-year and 5-year OS rates were of 54.5% (18 patients) and 30.3% (10 patients) respectively. Conclusion  Primary tumors in advanced stages, histological grade, and presence of nodal metastasis are poor prognostic markers in terms of long-term survival.

Nodal metastasis in surgically treated laryngeal squamous cell carcinoma

BACKGROUND

Management of the neck in laryngeal squamous cell carcinoma (LSCC) is essential to oncologic control and survival. We aim to describe patterns and rates of clinical/pathologic lymph node disease, elective neck dissection (END), and occult lymph node metastasis (LNM) in patients with surgically-managed LSCC.

METHODS

Retrospective cohort study of patients in the National Cancer Database (NCDB) diagnosed with LSCC between January 2004 and December 2016 who underwent primary surgery.

RESULTS

Seven thousand eight hundred and seventy-six patients met inclusion criteria. For cN0 patients, the rates of END and occult LNM both increased with tumor stage and were highest for supraglottic tumors. Predictors of occult LNM included supraglottic site, pathologic T3 and T4 stage, positive margins, and presence of lymphovascular invasion (p < 0.05).

CONCLUSIONS

The propensity for cervical LNM in surgically-managed LSCC varies based on primary tumor site and stage, and a variety of disease factors increase risk of occult LNM.

The epidemiology of oral cancer during the COVID-19 pandemic in Northern Italy: Incidence, survival, prevalence

Despite novel treatment approaches, oral cancer survival has not improved significantly and the disease often presents a disabling path for patients. The aim of this work was to describe the epidemiological data of oral cancers in a province of northern Italy. Incident cases in the period 1996–2020 and EU population standardized rates were reported for Oral Cavity cancer (OC) and OroPharyngeal cancer (OP). Annual percent changes (APC) were estimated with joint point analysis. The 5-year survival was calculated in three different periods: 1996–2000, 2001–2010 and 2011–2015. From 1996 to 2020, 771 cases of oral cancers (442 OC and 329 OP) were recorded with the age-standardized incidence rate 7.28 (10.74 in males and 3.97 in females): 3.82 for OC and 3.47 for OP. In males there is a significant increase in the incidence of OP up to 2017 (APC 11; 95% CI, 4.9–17.5), which then decreases; in females the rates are constant. In 2020 (the era of Covid-19), we did not see a decline in incidence compared to 2019. The 5-year survival (for cases diagnosed in 2011–2015) was 55.6%, 56.5% and 56% for OC, OP and OC + OP, respectively; it was somewhat higher in females and was undergoing some changes over the course of years. The number of prevalent cases as of 1 January 2021 is 314 (175 OC, 139 OP). The study showed a decline in cancers in men, particularly for OP; survival shows improvement in the long-term examined; Covid-19 had no negative impact on 2020 diagnoses.

Factors Associated With Oral Cancer Adverse Outcome at the Rwanda Military Hospital, a Retrospective Cross-Sectional Study

Oral cancer (OC) is one of the most common cancers that remain global public health concerns in low- and middle-income countries. The epidemiology of OC in Africa endures uncertain. Earlier reports suggested a relatively low incidence of OC among Africans. Acting on behavioral factors and setting early diagnosis and treatments of OC can tremendously reduce morbidity and mortality related to it. This study determined factors associated with the OC adverse outcome and death in the Rwanda Military Hospital. A cross-sectional study was conducted among 311 medical records of patients who consulted in the Oral and Maxilla Facial Department between January 1, 2007 and December 31, 2019. Associated factors were estimated by use of odds ratios (OR) with their 95% confidence intervals (CI) in bivariate and multivariate logistic regression analyses to estimate predictors of an OC adverse outcome and death. Almost three quarters of the participants were from rural areas (n = 229, 73.6%) and alcohol users (n = 247, 79.1%). Concerning primary site infection, 54.02% of the participants had the intra-oral cavity within the past 5 years. Muslims had greater odds to experience an OC adverse outcome and death [aOR = 6.7; 95% CI (3.8–11.9), p < 0.001] than the Catholics. Those with no formal education significantly had greater likelihoods to have an OC adverse outcome and death [aOR = 2.6; 95% CI (1.3–5.3), p = 0.005] than those with higher education or university. Those with primary education had greater likelihoods [aOR = 1.8; 95% CI (1.1–3.1), p = 0.03] to have an OC adverse outcome than those with higher or university education. Those with oral hygiene had less risk to have an OC adverse outcome and death [aOR = 0.2; 95% CI (0.0–0.9), p = 0.039] than their counterparts. Using multi-sectorial approaches, including policy makers, clinicians, and researchers from public and private institutions, may be of an added value to promote clinical research on OC for earning knowledge, contributing to combat risk behaviors and improve the population's information and education on OC prevention.

Head and Neck Squamous Cell Carcinoma: Risk Factors, Molecular Alterations, Immunology and Peptide Vaccines

Head and neck squamous cell carcinoma (HNSCC) arises from the epithelial lining of the oral cavity, hypopharynx, oropharynx, and larynx. There are several potential risk factors that cause the generation of HNSCC, including cigarette smoking, alcohol consumption, betel quid chewing, inadequate nutrition, poor oral hygiene, HPV and Epstein–Barr virus, and Candida albicans infections. HNSCC has causative links to both environmental factors and genetic mutations, with the latter playing a more critical role in cancer progression. These molecular changes to epithelial cells include the inactivation of cancer suppressor genes and proto-oncogenes overexpression, resulting in tumour cell proliferation and distant metastasis. HNSCC patients have impaired dendritic cell (DC) and natural killer (NK) cell functions, increased production of higher immune-suppressive molecules, loss of regulatory T cells and co-stimulatory molecules and major histocompatibility complex (MHC) class Ι molecules, lower number of lymphocyte subsets, and a poor response to antigen-presenting cells. At present, the standard treatment modalities for HNSCC patients include surgery, chemotherapy and radiotherapy, and combinatorial therapy. Despite advances in the development of novel treatment modalities over the last few decades, survival rates of HNSCC patients have not increased. To establish effective immunotherapies, a greater understanding of interactions between the immune system and HNSCC is required, and there is a particular need to develop novel therapeutic options. A therapeutic cancer vaccine has been proposed as a promising method to improve outcome by inducing a powerful adaptive immune response that leads to cancer cell elimination. Compared with other vaccines, peptide cancer vaccines are more robust and specific. In the past few years, there have been remarkable achievements in peptide-based vaccines for HNSCC patients. Here, we summarize the latest molecular alterations in HNSCC, explore the immune response to HNSCC, and discuss the latest developments in peptide-based cancer vaccine strategies. This review highlights areas for valuable future research focusing on peptide-based cancer vaccines.

Trends in Cancer Treatment for Oral Cavity, Oropharynx, and Larynx in 2016 Versus 2009: SEER Patterns of Care Studies

PURPOSE

To determine if there was a higher percentage of patients treated surgically and with advanced radiotherapy in 2016 (N = 897) versus 2009 (N = 1136), the patient and tumor characteristics associated with surgical care and advanced radiotherapy, and if chemotherapy or targeted agent use varied over time for squamous cell carcinoma of the head and neck.

METHODS

We utilized Surveillance Epidemiology and End Results Patterns of Care datasets. Rao-Scott Chi-square tests and logistic regressions were applied to determine differences in surgery, advanced radiotherapy (RT), and chemotherapy by year.

RESULTS

There was a lower prevalence of surgery only treatment in 2016 versus 2009 with exception of oral cavity stages IVB/IVC and unknown, and larynx stage unknown. Advanced RT was more common in 2016 for patients receiving definitive RT among all sites, excluding stages I/II glottic larynx. Among each site (oral cavity, oropharynx, and larynx) lower stage was associated with increased odds of surgery. Among each site, advanced RT was more common in patients receiving definitive versus postoperative RT. For the larynx site, 2016 versus 2009 was associated with greater odds of advanced RT. Systemic treatment with fluorouracil, taxanes, or cetuximab was less prevalent in 2016.

CONCLUSION

In 2016 versus 2009, there was largely not a higher percentage of patients treated surgically. There was a higher prevalence of advanced RT for definitive care. Further investigations of these patterns are needed, including trend analysis.

Assessment of surgical tumor-free resection margins in fresh squamous-cell carcinoma resection specimens of the tongue using a clinical MRI system

BACKGROUND

Current intraoperative methods of visual inspection and tissue palpation by the surgeon, and frozen section analysis cannot reliably prevent inadequate surgical margins in patients treated for oral squamous-cell carcinoma (OSCC). This study assessed feasibility of MRI for the assessment of surgical resection margins in fresh OSCC specimens.

METHODS

Ten consecutive tongue specimens containing OSCC were scanned using 3 T clinical whole-body MRI. Two radiologists independently annotated OSCC location and minimal tumor-free margins. Whole-mount histology was the reference standard.

RESULTS

The positive predictive values (PPV) and negative predictive values (NPV) for OSCC localization were 96% and 75%, and 87% and 79% for reader 1 and 2, respectively. The PPV and NPV for identification of margins <5 mm were 38% and 91%, and 5% and 87% for reader 1 and 2, respectively.

CONCLUSIONS

MRI accurately localized OSCC with high inter-reader agreement in fresh OSCC specimens, but it seemed not yet feasible to accurately assess the surgical margin status.

Does the Brown classification of maxillectomy defects have prognostic prediction for patients with oral cavity squamous cell carcinoma involving the maxilla?

The aim of this study was to investigate the correlation between the maxillectomy defect, T stage, and prognosis of patients with maxillary squamous cell carcinoma (SCC). The Brown classification system was used to appraise the maxillectomy defects due to maxillary SCC. The clinical data of 137 patients with maxillary SCC during the period 2000-2010 were reviewed; 105 patients were followed up. Preoperative T stage and postoperative maxillectomy class were recorded. The relationship between the maxillectomy defect class and T stage of maxillary SCC was analysed. Correlations between the maxillectomy defect class, local recurrence rate, and survival rate were assessed using IBM SPSS Statistics v19.0. The most common maxillectomy defect class was IIb (54.7%, 75/137). The maxillectomy defect class was significantly associated with the T stage (P < 0.001). Both T stage and the maxillectomy defect class were significantly associated with the survival rate of patients with maxillary SCC (both P< 0.001). In conclusion, the class of the maxillectomy defect was found to be associated with the T stage. Both of these were prognostic factors for patients with maxillary SCC. The class of the maxillectomy defect is suitable for clinical application in predicting the prognosis compared with T stage.

Head and Neck Cancer Detection in Digitized Whole-Slide Histology Using Convolutional Neural Networks

Primary management for head and neck cancers, including squamous cell carcinoma (SCC), involves surgical resection with negative cancer margins. Pathologists guide surgeons during these operations by detecting cancer in histology slides made from the excised tissue. In this study, 381 digitized, histological whole-slide images (WSI) from 156 patients with head and neck cancer were used to train, validate, and test an inception-v4 convolutional neural network. The proposed method is able to detect and localize primary head and neck SCC on WSI with an AUC of 0.916 for patients in the SCC testing group and 0.954 for patients in the thyroid carcinoma testing group. Moreover, the proposed method is able to diagnose WSI with cancer versus normal slides with an AUC of 0.944 and 0.995 for the SCC and thyroid carcinoma testing groups, respectively. For comparison, we tested the proposed, diagnostic method on an open-source dataset of WSI from sentinel lymph nodes with breast cancer metastases, CAMELYON 2016, to obtain patch-based cancer localization and slide-level cancer diagnoses. The experimental design yields a robust method with potential to help create a tool to increase efficiency and accuracy of pathologists detecting head and neck cancers in histological images.

Hyperspectral Imaging of Head and Neck Squamous Cell Carcinoma for Cancer Margin Detection in Surgical Specimens from 102 Patients Using Deep Learning

Surgical resection of head and neck (H and N) squamous cell carcinoma (SCC) may yield inadequate surgical cancer margins in 10 to 20% of cases. This study investigates the performance of label-free, reflectance-based hyperspectral imaging (HSI) and autofluorescence imaging for SCC detection at the cancer margin in excised tissue specimens from 102 patients and uses fluorescent dyes for comparison. Fresh surgical specimens (n = 293) were collected during H and N SCC resections (n = 102). The tissue specimens were imaged with reflectance-based HSI and autofluorescence imaging and afterwards with two fluorescent dyes for comparison. A histopathological ground truth was made. Deep learning tools were developed to detect SCC with new patient samples (inter-patient) and machine learning for intra-patient tissue samples. Area under the curve (AUC) of the receiver-operator characteristic was used as the main evaluation metric. Additionally, the performance was estimated in mm increments circumferentially from the tumor-normal margin. In intra-patient experiments, HSI classified conventional SCC with an AUC of 0.82 up to 3 mm from the cancer margin, which was more accurate than proflavin dye and autofluorescence (both p < 0.05). Intra-patient autofluorescence imaging detected human papilloma virus positive (HPV+) SCC with an AUC of 0.99 at 3 mm and greater accuracy than proflavin dye (p < 0.05). The inter-patient results showed that reflectance-based HSI and autofluorescence imaging outperformed proflavin dye and standard red, green, and blue (RGB) images (p < 0.05). In new patients, HSI detected conventional SCC in the larynx, oropharynx, and nasal cavity with 0.85-0.95 AUC score, and autofluorescence imaging detected HPV+ SCC in tonsillar tissue with 0.91 AUC score. This study demonstrates that label-free, reflectance-based HSI and autofluorescence imaging methods can accurately detect the cancer margin in ex-vivo specimens within minutes. This non-ionizing optical imaging modality could aid surgeons and reduce inadequate surgical margins during SCC resections.

Hyperspectral imaging for head and neck cancer detection: specular glare and variance of the tumor margin in surgical specimens

Head and neck squamous cell carcinoma (SCC) is primarily managed by surgical cancer resection. Recurrence rates after surgery can be as high as 55%, if residual cancer is present. Hyperspectral imaging (HSI) is evaluated for detection of SCC in ex-vivo surgical specimens. Several machine learning methods are investigated, including convolutional neural networks (CNNs) and a spectral-spatial classification framework based on support vector machines. Quantitative results demonstrate that additional data preprocessing and unsupervised segmentation can improve CNN results to achieve optimal performance. The methods are trained in two paradigms, with and without specular glare. Classifying regions that include specular glare degrade the overall results, but the combination of the CNN probability maps and unsupervised segmentation using a majority voting method produces an area under the curve value of 0.81 [0.80, 0.83]. As the wavelengths of light used in HSI can penetrate different depths into biological tissue, cancer margins may change with depth and create uncertainty in the ground truth. Through serial histological sectioning, the variance in the cancer margin with depth is investigated and paired with qualitative classification heat maps using the methods proposed for the testing group of SCC patients. The results determined that the validity of the top section alone as the ground truth may be limited to 1 to 2 mm. The study of specular glare and margin variation provided better understanding of the potential of HSI for the use in the operating room.

In-Vivo and Ex-Vivo Tissue Analysis through Hyperspectral Imaging Techniques: Revealing the Invisible Features of Cancer

In contrast to conventional optical imaging modalities, hyperspectral imaging (HSI) is able to capture much more information from a certain scene, both within and beyond the visual spectral range (from 400 to 700 nm). This imaging modality is based on the principle that each material provides different responses to light reflection, absorption, and scattering across the electromagnetic spectrum. Due to these properties, it is possible to differentiate and identify the different materials/substances presented in a certain scene by their spectral signature. Over the last two decades, HSI has demonstrated potential to become a powerful tool to study and identify several diseases in the medical field, being a non-contact, non-ionizing, and a label-free imaging modality. In this review, the use of HSI as an imaging tool for the analysis and detection of cancer is presented. The basic concepts related to this technology are detailed. The most relevant, state-of-the-art studies that can be found in the literature using HSI for cancer analysis are presented and summarized, both in-vivo and ex-vivo. Lastly, we discuss the current limitations of this technology in the field of cancer detection, together with some insights into possible future steps in the improvement of this technology.

Optical biopsy of head and neck cancer using hyperspectral imaging and convolutional neural networks

For patients undergoing surgical cancer resection of squamous cell carcinoma (SCCa), cancer-free surgical margins are essential for good prognosis. We developed a method to use hyperspectral imaging (HSI), a noncontact optical imaging modality, and convolutional neural networks (CNNs) to perform an optical biopsy of ex-vivo, surgical gross-tissue specimens, collected from 21 patients undergoing surgical cancer resection. Using a cross-validation paradigm with data from different patients, the CNN can distinguish SCCa from normal aerodigestive tract tissues with an area under the receiver operator curve (AUC) of 0.82. Additionally, normal tissue from the upper aerodigestive tract can be subclassified into squamous epithelium, muscle, and gland with an average AUC of 0.94. After separately training on thyroid tissue, the CNN can differentiate between thyroid carcinoma and normal thyroid with an AUC of 0.95, 92% accuracy, 92% sensitivity, and 92% specificity. Moreover, the CNN can discriminate medullary thyroid carcinoma from benign multinodular goiter (MNG) with an AUC of 0.93. Classical-type papillary thyroid carcinoma is differentiated from MNG with an AUC of 0.91. Our preliminary results demonstrate that an HSI-based optical biopsy method using CNNs can provide multicategory diagnostic information for normal and cancerous head-and-neck tissue, and more patient data are needed to fully investigate the potential and reliability of the proposed technique.

Cancer Detection Using Hyperspectral Imaging and Evaluation of the Superficial Tumor Margin Variance with Depth

Head and neck squamous cell carcinoma (SCCa) is primarily managed by surgical resection. Recurrence rates after surgery can be as high as 55% if residual cancer is present. In this study, hyperspectral imaging (HSI) is evaluated for detection of SCCa in ex-vivo surgical specimens. Several methods are investigated, including convolutional neural networks (CNNs) and a spectral-spatial variant of support vector machines. Quantitative results demonstrate that additional processing and unsupervised filtering can improve CNN results to achieve optimal performance. Classifying regions that include specular glare, the average AUC is increased from 0.73 [0.71, 0.75 (95% confidence interval)] to 0.81 [0.80, 0.83] through an unsupervised filtering and majority voting method described. The wavelengths of light used in HSI can penetrate different depths into biological tissue, while the cancer margin may change with depth and create uncertainty in the ground-truth. Through serial histological sectioning, the variance in cancer-margin with depth is also investigated and paired with qualitative classification heat maps using the methods proposed for the testing group SCC patients.

Expression of cytosolic malic enzyme (ME1) is associated with disease progression in human oral squamous cell carcinoma

Malic enzyme 1 (ME1) is a multifunctional protein involved in glycolysis, the citric acid cycle, NADPH production, glutamine metabolism, and lipogenesis. It is overexpressed in various cancers. We examined the expression of ME1 in 119 oral squamous cell carcinomas (OSCCs) using immunohistochemistry. Malic enzyme 1 expression was moderate to strong in 57 (48%) OSCCs and correlated with pT, pN, clinical stage, and histological grade. In 37 cases with prognostic evaluation, moderate to strong ME1 expression indicated a worse prognosis than did weak ME1 expression. Malic enzyme 1 knockdown or inactivation by lanthanide inhibited cell proliferation and motility and suppressed the epithelial-mesenchymal transition in HSC3 human OSCC cells. Knockdown of ME1 also shifted energy metabolism from aerobic glycolysis and lactate fermentation to mitochondrial oxidative phosphorylation, and the redox status from reductive to oxidative. In a mouse tumor model, lanthanide suppressed tumor growth and increased survival time. These findings reveal that ME1 is a valid target for molecular therapy in OSCC.

Overexpression of TMOD1 is associated with enhanced regional lymph node metastasis in human oral cancer

Tropomodulin1 (TMOD1), which regulates the length and depolymerization of actin filaments by binding to the pointed end of the actin filament, has been reported to be a powerful diagnostic marker for ALK-negative anaplastic large-cell lymphoma; however, little is known about the relevance of TMOD1 in the behavior of oral squamous cell carcinoma (OSCC). We evaluated TMOD1 expression in OSCC-derived cell lines and primary OSCC samples (n=200) using quantitative reverse transcriptase-polymerase chain reaction, immunoblotting and semi-quantitative immunohistochemistry. We also analyzed the clinical correlation between TMOD1 expression status and clinical parameters in patients with OSCC and performed a prospective study using 40 primary OSCC samples. TMOD1 expression was upregulated significantly (p<0.05) in OSCC in vitro and in vivo compared with normal counterparts. TMOD1 expression also was correlated significantly (p=0.0199 and p=0.0064, respectively) with regional lymph node metastasis (RLNM) and 5-year survival rates. This prospective study also showed that high TMOD1 expression was seen in 12 (75%) of 16 cases in RLNM-positive patients and 9 (37.5%) of 24 cases in RLNM-negative patients. The current data provide the first evidence that TMOD1 expression is a critical biomarker for RLNM and prognosis of patients with OSCC.

Quality of life after different oncologic interventions in head and neck cancer patients

Patient reported outcomes following head and neck cancer are of great importance, given the functional, psychological, and social impacts of the disease and its treatment. In addition, not only is the number of publications on health-related quality of life (HRQOL) increasing in a variety of specialties, but there is also a growing awareness of the potential role of HRQOL in practice. Therefore, we aimed to investigate the HRQOL of head and neck cancer patients following different oncologic interventions, using an internationally established test. In this cross-sectional study, we included three different groups of 32 patients each. Participants had histologically confirmed invasive oral squamous cell carcinoma (OSCC) in the anterior floor of the mouth. Group allocation was based on treatment modality, as follows: only surgery (group 1), operation and adjuvant radiotherapy (XRT) (group 2), and the additional presence of osteoradionecrosis (ORN) (group 3). All patients were questioned about their HRQOL, using the standardized University of Washington Quality of Life Questionnaire (UW-QOL). Surveys for groups 1 and 2 were conducted at least 24 months after the end of tumor-related treatment, in cases of ORN (group 3) 12 months after completion of disease-related treatment. A total of 96 patients were included into this study. The mean age was 62.79 ± 8.93 years. The patients in groups 1 and 2 revealed a reduced quality of life, of a greater magnitude after radiation therapy. Patients felt that radiotherapy was much worse than surgery; however, half of the patients stated that they would repeat radiation therapy if necessary. The subjective evaluation of the HRQOL after surgery and radiotherapy was a valuable instrument for assessing the rehabilitation of patients in the context of their function and quality of life. Radiation therapy can be considered a trigger of functional limitations and emotional distress that contributes to decreased HRQOL in patients with head and neck cancer.

Sevoflurane attenuate hypoxia-induced VEGF level in tongue squamous cell carcinoma cell by upregulating the DNA methylation states of the promoter region

Anaesthetic agents were confirmed to play a role on the tumor angiogenesis. The effect of sevoflurane on tongue squamous cell carcinoma (TSCC) cell has not been investigated. SCC-4 cells were exposed to sevoflurane after simulating hypoxia. Then, both the mRNA and protein level of hypoxia-inducible factor (HIF)-1α and VEGF were detected. The methylation states of the VEGF promoter region were also assessed to reveal the underlying mechanism. Finally, the DNA methyltransferase inhibitor 5-aza-2'-deoxycytidine (5-Aza) was administrated to reveal the relationship of DNA methylation on the regulation of the VEGF level. Results showed that sevoflurane attenuated the hypoxia-induced VEGF level without altering the HIF-1α after exposure for 24 and 72 h. Sevoflurane increased the DNA methylation of the VEGF promoter region. The attenuation effect of sevoflurane on hypoxia-induced VEGF level could be blocked by 5-Aza. We concluded that sevoflurane attenuates hypoxia-induced VEGF level via DNA methylation of the promoter region in TSCC cell.

Risk factors and treatment of contralateral neck recurrence for unilateral oral squamous cell carcinoma: a retrospective study of 1482 cases

BACKGROUND

The aim of this study was to describe risk factors of contralateral neck recurrence (CLNR) and to identify its high-risk population after treatment for unilateral oral squamous cell carcinoma.

METHODS

Between June 1991 and June 2012, a total of 1482 eligible patients who were treated with radical surgery with or without adjuvant therapy were retrospectively reviewed.

RESULTS

The outcome assessment parameters were the rate of 5-year CLNR and the rate of disease-specific survival (DSS). In the entire study cohort, the 5-year CLNR rate was 4.1%. In a multivariate analysis, only extracapsular spread (ECS) status (hazard ratio [HR]: 12.978, 95% confidence interval [CI]: 1.328-126.829, P=0.028) was an independent risk factor for 5-year CLNR. In addition, 5-year CLNR (HR: 36.410, 95% CI: 7.093-186.914, P<0.001), T stage (HR: 3.475, 95% CI: 1.151-10.488, P=0.027) and growth pattern (HR: 4.831, 95% CI: 1.776-13.140, P=0.002) were independent risk factors for 5-year DSS. Patients with at least two risk factors were identified as a high-risk population for CLNR; these patients also had a poor prognosis. Elective contralateral neck dissection (ND) plus concurrent chemoradiotherapy (CCRT) can improve the 5-year DSS in these high-risk patients, but it does not decrease the 5-year CLNR rate.

CONCLUSION

For low- and moderate-risk patients, contralateral neck observation should be considered sufficient if strict compliance with a cancer surveillance protocol is followed. However, whether high-risk patients benefit from contralateral ND plus adjuvant CCRT can only be answered in a prospective trial.

ANGPTL4 regulates the metastatic potential of oral squamous cell carcinoma

Lymph node metastasis is a major factor for poor prognosis in oral squamous cell carcinoma (OSCC). However, the molecular mechanisms of lymph node metastasis are unclear. We determined that angiopoietin-like protein 4 (ANGPTL4) mRNA and protein expression were increased in OSCC cells established from the primary site in metastatic cases. In addition, ANGPTL4 expression in biopsy specimens was correlated with the presence of lymph node metastasis. Therefore, our initial findings suggest that OSCC cells expressing ANGPTL4 may possess metastatic ability. Furthermore, cell culture supernatants from OSCC cells that metastasized to the lymph node contain ANGPTL4 and promote invasive ability. These findings suggest that secreted ANGPTL4 may affect the invasive ability of OSCC. Moreover, the rates of positive ANGPTL4 expression at the primary site were significantly higher in the lymph node metastasis group. These results demonstrate that ANGPTL4 contributes to OSCC metastasis by stimulating cell invasion. Therefore, ANGPTL4 is a potential therapeutic target for preventing cancer metastasis.

ECRG4 inhibits growth and invasiveness of squamous cell carcinoma of the head and neck in vitro and in vivo

ECRG4 has been shown to be a candidate tumor suppressor in several tumors, but its role in head and neck cancer remains poorly understood. In the present study, the effect of ECRG4 on head and neck cancer was investigated in vitro and in vivo. pFLAG-CMV-2-ECRG4 was stably transfected into squamous cell carcinoma of the head and neck (SCCHN) M2 cell lines to overexpress the ECRG4 gene. Real-time PCR and western blot analysis were performed to detect gene and protein expression, respectively. An MTT assay and flow cytometric analysis were used to detect the growth of M2 cells. Matrigel™ invasion and scratch assays were applied to observe the invasion and migration of the cells. A tumorigenicity assay was applied to test the tumor growth and cervical lymph node metastasis in vivo. Based on the data, pFLAG-CMV-2-ECRG4 significantly increased the expression of ECRG4 in the M2 cells. The constructed plasmid inhibited cell proliferation and promoted cell cycle arrest and apoptosis in the M2 cells. The growth rate and metastasis of the tumor cells in xenografts were suppressed following the overexpression of ECRG4 in nude mice. These data suggest that ECRG4 plays a significant role in the regulation of growth and metastasis in SCCHN, providing new clues for the diagnosis and therapy of SCCHN.

Lin28a is a putative factor in regulating cancer stem cell-like properties in side population cells of oral squamous cell carcinoma

Cancer stem cells (CSCs) are among the target cells of cancer therapy because they are uniquely involved in both cancer progression and sensitivity to chemotherapeutic agents. We identified side population (SP) cells, which are known to be an enriched population of CSC, in five oral squamous cell carcinoma (OSCC) cells (SCC9, SCC25, TOSCC7, TOSCC17, and TOSCC23). The percentages of SP cells ranged from 0% to 3.3%, with TOSCC23 cells showing the highest percentages of SP cells (3.3% of the total cell population). The SP cells isolated from TOSCC23 cells also showed greater cell proliferation and invasion compared to non-SP (MP) cells. Therefore, our initial findings suggested that SP cells were enriched for CSC-like cells. Furthermore, DNA microarray analysis revealed that the expression of cell proliferation-related and anti-apoptotic genes was greater in SP cells compared to MP cells. We focused on Lin28a, which showed the highest expression (approximately 22-fold) among the upregulated genes. The overexpression of Lin28a in TOSCC23 cells increased their proliferation, colony formation, and invasion. These findings suggest that Lin28a is an appropriate CSC target molecule for OSCC treatment.

Heat generation and transfer behaviors of ti-coated carbon steel rod adaptable for ablation therapy of oral cancer

For the purpose of developing a novel ablation therapy for oral cancer, the heat generation and transfer properties of a Ti-coated carbon steel rod with 20-mm length and 1.8-mm outer diameter were investigated by means of a high-frequency induction technique at 300 kHz. The heat generation measurement performed using water (15 mL) revealed that the difference of the inclination angles (θ = 0°, 45° and 90°) relative to the magnetic flux direction only slightly affects the heating behavior, exhibiting the overlapped temperature curves during an induction time of 1200 s. These results suggest that the effect of the shape magnetic anisotropy is almost eliminated, being convenient for the precise control of the ablation temperature in clinical use. In the experiments utilizing a tissue-mimicking phantom, the heat transfer concentrically occurred in the lateral direction for both the planar surface and a 10-mm deep cross-section. However, the former exhibited a considerably lower increase in temperature (ΔT), probably due to the effect of heat dissipation to the ambient air. No significant heat transfer was found to occur to the lower side of the inserted Ti-coated carbon steel rod, which is situated in the longitudinal direction.

Autocrine IL-1β-TRAF6 signalling promotes squamous cell carcinoma invasion through paracrine TNFα signalling to carcinoma-associated fibroblasts

The invasion of squamous cell carcinoma (SCC) is a significant cause of morbidity and mortality. Here, we identify an E3 ligase, Traf6 and a de-ubiquitinating enzyme, Cezanne/ZA20D1, as important regulators of this process in organotypic models. Traf6 can promote the formation of Cdc42-dependent F-actin microspikes. Furthermore, Traf6 has a key role in autocrine interleukin-1β signalling in SCC cells, which in turn is required to drive the expression of tumour necrosis factor α (TNFα). TNFα acts in a paracrine manner to increase the invasion-promoting potential of carcinoma-associated fibroblasts (CAFs). Exogenous TNFα signalling can restore invasion in cells depleted of Traf6. In conclusion, Traf6 has two important roles in SCC invasion: it promotes cell intrinsic Cdc42-dependent regulation of the actin cytoskeleton and enables production of the paracrine signal, TNFα, that enhances the activity of CAFs.

Elective neck dissection versus "wait and watch" policy in tongue carcinoma

Aim:

To evaluate the efficacy of elective neck dissection versus the “wait and watch” policy in the treatment of early squamous cell carcinoma of tongue.

Materials and Methods:

This is a retrospective study of 21 patients with surgical treatment between April 2009 and July 2011. The patients were divided into two groups, with Group 1 consisting of patients who underwent wide excision glossectomy with elective neck dissection and Group 2 consisting of patients who underwent glossectomy without the neck being surgically addressed. The selection of patients was done by the random double-blinded method and the review was done by a single reviewer. All patients were examined for an average period of 1 year postoperatively.

Results:

Twenty-one cases were treated, among which there were 17 T1 and 4 T2 carcinomas. All the patients had primary carcinoma involving only the tongue with no clinical neck palpable neck nodes. Eleven patients underwent wide excision of primary tumor with elective neck dissection (Group 1) and 10 patients underwent only resection of primary tumor without the neck being surgically addressed (Group 2). In Group 1, there were no recurrences, and in Group 2, there were two patients who developed subsequent cervical node metastasis with one patient undergoing further surgery to address the positive neck and the other patient was lost to follow-up.

Conclusions:

Regional recurrence was the most common cause of failure after surgical treatment of oral tongue carcinoma. Elective neck dissection significantly reduced mortality due to regional recurrence and also increased the overall survival. Our study suggests that elective neck dissection is a treatment strategy of choice for stages I and II carcinoma of the oral tongue. A prospective, randomized study is worthwhile to further evaluate the benefit of elective neck dissection in the treatment of early carcinoma of the tongue with a larger pool of patients and a lengthier follow-up period.

In vitro cytotoxic effects of Brazilian plant extracts on squamous cell carcinoma of the oral cavity

Squamous cell carcinoma (SCC) is the most prevalent cancer of the oral cavity and the fifth most prevalent of all malignancies in males. Many researchers have attempted to develop new treatments that will improve the prognosis of SCC patients. Over 20% of the world's biodiversity is located within the Brazilian forests, but little is known about the chemical and/or pharmacological potential of these plants. Certain extracts obtained from Amazon and Atlantic Forest plants have previously been shown to have cytotoxic activity against various cancers. The aim of this study was to screen these extracts for cytotoxic activity against oral SCC cells. The extracts were analyzed for activity against the KB-ADL#12 cell line at various concentrations up to a maximum dose of 100 µg/mL. Comparisons with a control group were performed using one-way ANOVA. Significant cytotoxicity was induced by the extracts obtained from the aerial parts of Picrolemma sprucei (Simaroubaceae), from the leaves and stems of Laetia suaveolens (Salicaceae), from the aerial parts of Abarema auriculata (Fabaceae-Mimosoideae) and from the stem of A. auriculata.

Detection of TIMP3 promoter hypermethylation in salivary rinse as an independent predictor of local recurrence-free survival in head and neck cancer

PURPOSE

To validate a panel of methylation-based salivary rinse biomarkers (P16, CCNA1, DCC, TIMP3, MGMT, DAPK, and MINT31) previously shown to be independently associated with poor overall survival and local recurrence in a larger, separate cohort of patients with head and neck squamous cell carcinoma (HNSCC).

EXPERIMENTAL DESIGN

One hundred ninety-seven patients were included. All pretreatment saliva DNA samples were evaluated for the methylation status of the gene promoters by quantitative methylation-specific PCR. The main outcome measures were overall survival, local recurrence-free survival, and disease-free survival.

RESULTS

In univariate analyses, the detection of hypermethylation of CCNA1, MGMT, and MINT31 was significantly associated with poor overall survival; the detection of hypermethylation of TIMP3 was significantly associated with local recurrence-free survival; and the detection of hypermethylation of MINT31 was significantly associated with poor disease-free survival. In multivariate analyses, detection of hypermethylation at any single marker was not predictive of overall survival in patients with HNSCC; detection of hypermethylation of TIMP3 in salivary rinse had an independent, significant association with local recurrence-free survival (HR = 2.51; 95% CI: 1.10-5.68); and none of the studied markers was significantly associated with disease-free survival.

CONCLUSION

The detection of promoter hypermethylation of the seven genes in salivary rinse as an independent prognostic indicator of overall survival in patients with HNSCC was not validated. Detection of promoter hypermethylation of TIMP3 in pretreatment salivary rinse is independently associated with local recurrence-free survival in patients with HNSCC and may be a valuable salivary rinse biomarker for HNSCC recurrence.

Phase I clinical trial of survivin-derived peptide vaccine therapy for patients with advanced or recurrent oral cancer

Survivin, a member of the inhibitor of apoptosis protein (IAP) family, is abundantly expressed in most malignancies, but is hardly detectable in normal adult tissues. Previously we have identified a human leukocyte antigen (HLA)-A24-restricted antigenic peptide, survivin-2B80-88 (AYACNTSTL), recognized by CD8(+) cytotoxic T lymphocytes (CTL). Survivin-2B80-88-specific CTL were induced efficiently from peripheral blood mononuclear cells (PBMC) of oral cancer patients after stimulation with the peptide in vitro. We conducted a phase I clinical study to evaluate the safety and the efficacy of survivin-2B80-88 peptide vaccination in HLA-A24-positive patients with advanced or recurrent oral cancer. The vaccines were given subcutaneously or intratumorally six times at 14-day intervals. Eleven patients were enrolled and 10 patients completed the vaccination protocol. No adverse events were observed in any patients. In two patients, the levels of serum squamous cell carcinoma (SCC) antigen decreased transiently during the period of vaccination. Tumor regression that was compatible with a partial response (PR) was noted in one patient. The remaining nine patients experienced progressive disease (PD). Immunologically, an increase of the peptide-specific CTL frequency was detected in six of the eight patients evaluated by HLA-A24/peptide tetramer analysis. The present clinical trial revealed that survivin-2B peptide vaccination was safe and had therapeutic potential for oral cancer patients. However, subsequent clinical trials in combination with various adjuvant drugs will be required to improve the immunological and therapeutic efficacy. This trial was registered with University Hospital Medical Information Network (UMIN) number UMIN000000976.

Mutagenic evaluation of combined paclitaxel and cisplatin treatment in somatic cells of Drosophila melanogaster

Recent studies have added paclitaxel (PAC) to traditional cisplatin (CIS) regimen to treat squamous cell carcinoma of the head and neck. The target of these antineoplastic agents is nuclear DNA for CIS and microtubules for PAC, although it is not restricted to malignant cells. In this study, the genotoxicity of the combined treatment of PAC and CIS was investigated using the standard version of the wing Somatic Mutation and Recombination Test (SMART) in Drosophila melanogaster. Quantitative and qualitative genotoxic effects of these compounds were estimated by comparing wing spot frequencies in marker-heterozygous to balancer-heterozygous flies. Two different concentrations of PAC (0.0025 and 0.005mM) and CIS (0.025 and 0.05mM) as well as combinations of them were employed. The results demonstrated that the spindle poison PAC alone was not genotoxic in this test system, while CIS was able to induce a high incidence of DNA damage in both genotypes, mainly related to somatic recombination. The data obtained for the combined treatments showed that its genotoxicity varied with the concentrations used. In small concentrations the number of total spots induced by combination was reduced in relation to CIS 0.025mM just for marker-heterozygous flies, showing that somatic recombination was the prevalent event involved. At higher concentrations the combined treatment showed significant reductions in the frequencies of large single spots, for both genotypes, and twin spots for marker-heterozygous flies, but did not significantly reduce the total spots frequency in either genotype. The data suggest that aneugenic activity of PAC could be responsible for the reduction in the genotoxicity of CIS.

Management of patients who have undergone head and neck cancer therapy

Patients who undergo treatment for head and neck cancers often suffer from acute or late reactions to therapy. Severity of these oral complications may be based on the location and extent of tumor, as well as the type and extent of treatment. Some complications are transient, whereas others require a lifetime of management secondary to damage that results in permanent dysfunction. Patients who have a history of head and neck cancers are also at an increased risk for recurrences or second malignancies, and therefore require close follow-up. Dental professionals should provide preventive and supportive care, including education and symptom management, for patients experiencing oral complications related to cancer therapy, and should closely monitor patients' level of distress, ability to cope, and treatment response.