The Surgical Management of Oral Cancer

Prediction nomogram development and validation for postoperative radiotherapy in the management of oral squamous cell carcinoma

BACKGROUND

Predictive nomograms are useful tools to guide clinicians in estimating disease course. Oral squamous cell carcinoma (OSCC) patients would benefit from an interactive prediction calculator that defines their levels of survival-risk specific to their tumors to guide the use of postoperative radiotherapy (PORT).

METHODS

Patients with OSCC surgically treated with curative intent at four Head and Neck Cancer Centres were recruited retrospectively for development and validation of nomograms. Predictor variables include PORT, age, T and N classification, surgical margins, perineural invasion, and lymphovascular invasion. Outcomes were disease-free, disease-specific, and overall survivals over 5 years.

RESULTS

1296 patients with OSCC were in training cohort for nomogram analysis. Algorithms were developed to show relative benefit of PORT in survivals for higher-risk patients. External validation on 1212 patients found the nomogram to be robust with favorable discrimination and calibration.

CONCLUSION

The proposed calculator can assist clinicians and patients in the decision-making process for PORT.

Chemosensory Functions After Glossectomy-A Cross-Sectional Pilot Study

OBJECTIVE

To evaluate potential interactions and compensatory mechanisms of subjectively impaired taste function with ortho- and retronasal olfaction after glossectomy.

STUDY DESIGN

In this cross-sectional pilot study, chemosensory functions were assessed in 25 patients with tongue carcinomas after glossectomy. The orthonasal-, retronasal-, and gustatory functions were tested with a mean time of 25 months after surgery with the Sniffin' Sticks odor identification test kit (ISST), the Candy Smell-27 test (CST-27) and the Taste strip test (TST). Visual analog scales (VAS) were additionally used for self-assessment of taste, flavor perception, and odor ranging from 0 (no perception) to 10 (excellent perception) and further correlated with our psychophysical evaluated outcome measures.

RESULTS

The TST, ISST, and CST-27 tests revealed that only eight (32%) and 13 (52%) glossectomy patients had normal taste and orthonasal function, e 21 (84%) patients showed normal retronasal function. Importantly, neither extent of resection and reconstruction nor prior radiotherapy affected chemosensory functions. Contrary, 20 (80%) patients rated their taste and flavor perception as acceptable (VAS >5). Results of the TST, ISST, and CST-27 tests did not correlate with the equivalent self-assessments of taste (p = 0.260, r = 0.234), odor (p = 0.588, r = -0.114), and flavor (p = 0.728, r = 0.073) perception.

CONCLUSION

There was a significant discrepancy between self-perception of taste and flavor and assessed gustatory function after glossectomy. A contribution of the intact retronasal olfactory system could be a possible explanation of our results.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:375-382, 2023.

Comparison of quality of life and psychological distress in patients with tongue cancer undergoing a total/subtotal glossectomy or extended hemiglossectomy and free flap transfer: a prospective evaluation

The aim of this study was to assess changes in the quality of life and psychological distress of patients with tongue cancer undergoing total/subtotal glossectomy (TG) or extended hemiglossectomy (HG) and free flap transfer. Differences between the two groups were compared using the Short Form 8-Item Health Survey (SF-8) and Hospital Anxiety and Depression Scale (HADS). Of the 43 patients with tongue cancer, 24 (56%) underwent TG and 19 (44%) underwent HG. The general health and social functioning scores in the SF-8 and depression in the HADS were significantly worse in the TG group than in the HG group at 12 months after surgery, indicating that patients in the TG group may experience social isolation and psychological distress, and have difficulty in employability even 12 months after surgery. In contrast, all items of the SF-8 in the HG group were nearly equal to those in the general population. Due to the extensive psychological impact on patients with tongue cancer who are planned for an extended resection, curative surgery with free flap transfer and multidisciplinary psychiatric support are essential to improve quality of life and manage psychological distress.

Head and neck cancer

Head and neck cancer is the seventh most common type of cancer worldwide and comprise of a diverse group of tumours affecting the upper aerodigestive tract. Although many different histologies exist, the most common is squamous cell carcinoma. Predominant risk factors include tobacco use, alcohol abuse, and oncogenic viruses, including human papillomavirus and Epstein-Barr virus. Head and neck malignancies remain challenging to treat, requiring a multidisciplinary approach, with surgery, radiotherapy, and systemic therapy serving as key components of the treatment of locally advanced disease. Although many treatment principles overlap, treatment is generally site-specific and histology-specific. This Seminar outlines the current understanding of head and neck cancer and focuses on treatment principles, while also discussing future directions to improve the outcomes of patients with these malignancies.

The Functional & Quality of Life Outcomes of Total Glossectomy with Laryngeal Preservation

BACKGROUND

The tongue is an essential organ for human interaction, communication and survival. To date, there is a paucity of objective functional, patient reported, or quality of life outcomes of patients undergoing a total glossectomy with preservation of the larynx (TGLP).

OBJECTIVE

To examine prospectively collected objective, self-reported functional and quality of life (QOL) data in patients undergoing TGLP and free flap reconstruction.

METHODS

Sixteen TGLP patients were identified in the prospective head and neck cancer and functional outcomes database between January of 2009 and December 2017. Data collection included patient age, sex, performance status, TNM staging, diagnosis and adjuvant treatment. Swallowing and speech functions were measured and prospectively recorded pre- and postoperatively. Patient reported outcomes were measured with the Speech Handicap Index (SHI) and the M.D. Anderson Dysphagia Inventory (MDADI).

RESULTS

All patients had a significant reduction in their objective swallowing (P = 0.035), sentence (P = 0.001) and word intelligibility (P < .001) scores. There was no significant reduction in SHI or total MDADI scores. All patients maintained their QOL in the post-treatment time frame. There was no relationship between free-flap type and outcome.

CONCLUSION

Total glossectomy with laryngeal sparing and free flap reconstruction results in significant reduction in objective functional measurements, but patients report stable functional and quality of life outcomes after treatment.

A comparative study of osteopontin expression, Ki67 index and prognosis in squamous cell carcinoma and cysts of the oral cavity

Background

Recent studies have shown a strong relationship between the expression of osteopontin and oral carcinogenesis. Osteopontin (OPN) has been shown to play a major role in regulating the aggressiveness of cancer cells and promote tumor growth. Odontogenic cysts are an essential aspect of oral and maxillofacial pathology. They are relatively frequent lesions with different clinical behavior. Some of them may have a proliferative pattern of growth and neoplastic nature. Evaluation of osteopontin expression with Ki-67 index may help examine clinical behavior and recurrence of oral squamous cell cancer and radicular cyst patients.

Methods

A total of 44 oral cavity cancer cases and 21 cysts samples were analyzed by immunohistochemical staining. Data used for analysis were derived from medical records. The following information was obtained from all patients’ medical records: survival, age, sex, lymph node status, tumor size, and location, as well as grade and histologic type of tumor. Expression status of OPN and Ki-67 was statistically assessed.

Results

Our data demonstrated that for summary immunoreactive scores of OPN and Ki-67 expressions in OSCC vs. RC patients statistical significance was found for both markers’ between OSCC and RC groups. Moreover, osteopontin is significantly higher expressed in larger OSCC tumors.

Conclusions

In conclusion, the role of OPN expression both in oral squamous cancer cells and radicular cyst and possible correlation with demographic and clinicopathological features remain undetermined in some aspects, further high-powered studies to develop a more standardized assessment of Ki-67 and osteopontin expression in OSCC and are needed.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Correlation Between Postoperative Health-Related Quality of Life and Care Needs of Oral Cancer Patients

Oral cancer is the fifth most common form of cancer in Taiwan in terms of incidence and death rate and results in at least 2700 deaths each year.

Profiling and bioinformatics analyses reveal differential expression of circular RNA in tongue cancer revealed by high-throughput sequencing

Circular RNAs (circRNA) are special noncoding RNAs. They are widely present, but with unknown functions. Recent studies have shown that many endogenous circRNAs have sponge function to absorb microRNAs (miRNA). They can regulate target gene messenger RNA expression and play important roles in many biological processes. However, expression profile and function of circRNAs in human tongue squamous cell carcinoma (TSCC) have not been reported. High-throughput sequencing was performed to identify and annotate from three TSCC tissues and adjacent tissues. A separate set (n = 20) of human TSCCs and corresponding adjacent tissues were subjected to reverse-transcription polymerase chain reaction (RT-PCR) for validation of circRNAs expression profile. Gene Ontology (GO) functional analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, and circRNA-miRNA network analysis were also performed to predict the function of circRNA in TSCC. A total of 12 156 circRNAs were identified and annotated, most of the circRNAs were novel ( n = 6231) and exonic (62.09%). Statistical analysis revealed 322 differentially expressed (DE) circRNAs. RT-PCR results showed that circRNA expression in TSCC was higher than that in adjacent tissues. GO functional analysis, KEGG pathway analysis, and circRNA-miRNA network analysis all showed that circRNAs correlated with tumor development and progression to a certain extent. The current study is the first to systematically characterize and annotate circRNA expression in TSCC, the majority were novel circRNAs. Some host genes of the DE circRNAs were involved in tumor signaling pathway and had complicated correlations with tumor-relevant miRNAs, indicating that circRNAs might be promoted development and progression of TSCC.

Impact of tumoral carbonic anhydrase IX and Ki-67 expression on survival in oral squamous cell carcinoma patients

Oral squamous cell carcinoma (OSCC) is the most commonly diagnosed type of head and neck cancer, accounting for ~300,000 new cases worldwide annually. Carbonic anhydrase IX (CAIX) and Ki-67 have been associated with reduced disease-specific survival (DSS) in patients with OSCC. We previously proposed a combined CAIX and Ki-67 signature of 'functional hypoxia' and sought to replicate this association in a larger independent cohort of patients with OSCC at the Fred Hutchinson Cancer Research Center (FHCRC) in Seattle. The study population included patients with incident primary OSCC treated at the University of Washington Medical Center and the Harborview Medical Center in Seattle between December 2003 and February 2012. Archived tumor blocks were obtained with tissue samples from 189 patients, and triplicate 0.6 mm cores were assembled into tissue microarrays (TMAs). Fluorescence immunohistochemistry and AQUAnalysis® were used to quantify the expression of tumoral CAIX (tCAIX) and stromal CAIX (sCAIX) and tumoral Ki-67 for each TMA core. Hazard ratios for DSS were calculated using Cox proportional hazards analysis. High tCAIX and sCAIX expression levels were associated with reduced DSS (aHR=1.003, 95% CI:1.00-1.01 and aHR=1.010, 95% CI:1.001-1.019, per AQUA score unit, respectively). Ki-67 expression was not associated with survival (aHR=1.01, 95% CI:0.99-1.02) in the FHCRC cohort. DSS for patients with high sCAIX and low Ki-67 did not differ from that of other patient groups. Elevated tCAIX was associated with reduced DSS as a continuous and as a dichotomized (75%) variable. sCAIX was associated with DSS as a continuous variable but not when dichotomized (75%). However, the previously proposed 'functional hypoxia' signature was not replicated in the current FHCRC study. The failure to replicate our prior observation of poorer survival in patients with combined high sCAIX and low tumoral Ki-67 was likely due to the absence of an association between tumoral Ki-67 and DSS in this cohort. However, the association between DSS and tCAIX and sCAIX supports a role for CAIX in OSCC clinical outcomes.

Critical risk-benefit assessment of the novel anti-cancer aurora a kinase inhibitor alisertib (MLN8237): A comprehensive review of the clinical data

BACKGROUND

Many current anticancer chemotherapeutics suffer from significant side effects, which have led to the exploration of more targeted therapies. This resulted in the exploration of inhibitors of Aurora A kinase as a potential anti-cancer treatment. Alisertib (MLN8237) has proven to be a potent Aurora A kinase inhibitor that had the highest safety profile among its therapeutic family. Phase I/II/III clinical trials with Alisertib have been carried out and reported promising efficacy, yet serious side effects. This article attempts to assess the clinical effect of Alisertib administration in various cancer phenotypes while describing the reported side effects.

METHODS

Alisertib clinical data were systematically retrieved from Medline, CINAHL, PubMed, and Cochrane Central Register of Controlled Trials and analyzed for quality, relevance, and originality in three stages prior to inclusion.

RESULTS

Overall, seven studies met inclusion criteria and enrolled a total of 630 patients. The reported "potential" clinical effect of Alisertib in various tumours is promising as it improved time to disease progression, progression-free survival, and the duration of disease stability. The achieved improvement therefore rationalizes its further investigation as a novel anticancer therapy. However, the administration of the drug was associated with serious haematological disturbances in a relatively high percentage of patients.

CONCLUSION

The evidence of the anti-tumour effect of Alisertib administration is compelling in various types of malignancies. The reported side effects were serious but manageable in many cases. Topical or more targeted routes of administration are suggested when possible to overcome off-target events with systematic administration of the drug.

Polymeric drug delivery systems for intraoral site-specific chemoprevention of oral cancer

Oral cancer is among the most prevalent cancers in the world. Moreover, it is one of the major health problems and causes of death in many regions of the world. The traditional treatment modalities include surgical removal, radiation therapy, systemic chemotherapy, or a combination of these methods. In recent decades, there has been significant interest in intraoral site-specific chemoprevention via local drug delivery using polymeric systems. Because of its easy accessibility and clear visibility, the oral mucosa is amenable for local drug delivery. A variety of polymeric systems-such as gels, tablets, films, patches, injectable systems (e.g., millicylindrical implants, microparticles, and in situ-forming depots), and nanosized carriers (e.g., polymeric nanoparticles, nanofibers, polymer-drug conjugates, polymeric micelles, nanoliposomes, nanoemulsions, and polymersomes)-have been developed and evaluated for the local delivery of natural and synthetic chemopreventive agents. The findings of in vitro, ex vivo, and in vivo studies and the positive outcome of clinical trials demonstrate that intraoral site-specific drug delivery is an attractive, highly effective and patient-friendly strategy for the management of oral cancer. Intraoral site-specific drug delivery provides unique therapeutic advantages when compared to systemic chemotherapy. Moreover, intraoral drug delivery systems are self-administrable and can be removed when needed, increasing patient compliance. This article covers important aspects and advances related to the design, development, and efficacy of polymeric systems for intraoral site-specific drug delivery. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1383-1413, 2018.

Endocavitary sonography of early oral cavity malignant tumors

BACKGROUND

Preoperative staging is crucial for oral cancer management. The purpose of this study was to assess the tumor thickness using ultrasound and to correlate the level of histological infiltration with the tumor superficial extension and lesion thickness.

METHODS

Thirty-two subjects affected by oral cavity carcinoma were prospectively evaluated with intraoral ultrasound. The ultrasound sensitivity, the correlation between the ultrasound level of infiltration, and lesion diameters and thickness were assessed.

RESULTS

A 91% ultrasound sensitivity was found with no significant correlation between tumor diameter and level of histological infiltration (P >.05). A thickness of <2 mm was associated to tumor extension to the lamina propria, a value of >6 mm to muscular layer infiltration. Lymph adenopathies were identified in 21% of cases, associated to muscular layer infiltration in all cases.

CONCLUSION

In the study of early oral cavity tumors, ultrasound is accurate for demonstrating the level of tumor infiltration and contributes to the therapeutic choice.

Neck dissection for oral squamous cell carcinoma: our experience and a review of the literature

Objectives

This article describes our experience with neck dissection in 10 patients with oral squamous cell carcinoma.

Materials and Methods

Between January 2007 and October 2009, 10 patients underwent primary surgery for the treatment of squamous cell carcinoma of the oral cavity. For patients with N₀ disease on clinical exam, selective neck dissection (SND [I-III]) was performed. In patients with palpable cervical metastases (N+), modified radical neck dissections were performed, except in one patient in whom SND (I-III) was performed. The histopathologic reports were reviewed to assess the surgical margins, the presence of extra-capsular spread, perineural invasion, and lymphatic invasion.

Results

On histopathologic examination, positive soft tissue margins were found in three patients, and regional lymph node metastases were present in five of the ten patients. Perineural invasion was noted in five patients, and extra nodal spread was found in four patients. Regional recurrence was seen in two patients and loco-regional recurrence plus distant metastasis to the tibia was observed in one patient. During the study period, three patients died. Seven patients remain free of disease to date.

Conclusion

Histopathological evaluation provides important and reliable information for disease staging, treatment planning, and prognosis. The philosophy of neck dissection is evolving rapidly with regard to the selectivity with which at-risk lymph node groups are removed. The sample size in the present study is small, thus, caution should be employed when interpreting these results.

Contralateral neck failure in lateralized oral squamous cell carcinoma

BACKGROUND

Elective treatment of the contralateral clinically node-negative (cN0) neck is not routinely recommended for lateralized oral cavity squamous cell carcinoma (SCC). We sought to determine the failure rate in the untreated contralateral neck in patients with lateralized oral SCC undergoing treatment of the primary and ipsilateral neck and to identify any features placing patients at sufficient risk of contralateral regional failure to justify elective treatment.

METHODS

We identified 688 patients with oral SCC undergoing curative surgery ± adjuvant therapy between 1985 and 2012 from a prospectively collected database. Patients with midline primaries and those undergoing bilateral neck treatment were excluded. The primary endpoint was isolated contralateral neck failure.

RESULTS

Of 481 patients, 14 (2.9%) developed isolated contralateral neck recurrence, with median time to recurrence of 8 months. Patients with poorly differentiated tumours or pathologically proven ipsilateral nodal metastases were at significantly higher risk of contralateral failure (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.1-11.9, P = 0.037 and HR 4.6, 95% CI 1.5-13.8, P = 0.006 respectively). Presence of both of these factors conferred a 10% risk of contralateral failure.

CONCLUSION

Patients with lateralized oral SCC undergoing treatment of the primary tumour and ipsilateral neck have a low rate of isolated contralateral neck failure. Although poorly differentiated primaries and ipsilateral nodal metastases were predictors of contralateral recurrence, the risk remains relatively modest in this subset of patients suggesting close observation may be more appropriate than elective treatment. Our results support current recommendations for observation of the cN0 contralateral neck in lateralized oral SCC.

The prognostic impact of a combined carbonic anhydrase IX and Ki67 signature in oral squamous cell carcinoma

Background:

Tumour hypoxia is associated with impaired apoptosis, resistance to therapy and poor prognosis. We previously reported that high stromal expression of the endogenous marker of hypoxia, carbonic anhydrase IX (CAIX), is associated with significantly reduced survival in oral squamous cell carcinoma (OSCC). In addition to hypoxia, CAIX expression is regulated by proliferation-associated signalling. We hypothesised that incorporating Ki67, a proliferation marker, into our existing CAIX-based stratification of OSCC would identify patients with the least favourable prognosis.

Methods:

Surgically resected tumours from 60 OSCC patients were analysed for CAIX, Ki67 and BAX expression using fluorescence immunohistochemistry and automated quantitative analysis (AQUA).

Results:

In patients expressing high stromal CAIX (sCAIX), stratification by tumour Ki67 expression revealed significantly distinct survival outcomes (P=0.005). In our OSCC cohort, below-median Ki67 and top-quartile sCAIX expression (Ki67^losCAIX^hi) were associated with significantly worse disease-specific survival in univariate (HR 7.2 (2.5–20.4), P=0.001) and multivariate (HR 4.2 (1.4–12.8), P=0.011) analyses. Hypoxia is associated with decreased BAX expression; the Ki67^losCAIX^hi group was more strongly associated with low BAX expression than high sCAIX alone.

Conclusion:

These data suggest that combined analysis of tumour Ki67 and sCAIX expression may provide a more clinically relevant assessment of tumour hypoxia in OSCC.

Fusogenic-oligoarginine peptide-mediated delivery of siRNAs targeting the CIP2A oncogene into oral cancer cells

Despite a better understanding of the pathogenesis of oral cancer, its treatment outcome remains poor. Thus, there is a need for new therapeutic strategies to improve the prognosis of this disease. RNA interference (RNAi) appears to be a promising therapeutic tool for the treatment of many diseases, including oral cancer. However, an obstacle for RNAi-mediated therapies has been delivery, in particular, the retention of small interfering RNAs (siRNAs) in endosomes and their subsequent degradation in lysosomes, resulting in inefficient gene silencing. Thus, the current study examined the feasibility of designing and utilizing a peptide, termed 599, consisting of a synthetic influenza virus-derived endosome-disruptive fusogenic peptide sequence and a stretch of cationic cell-penetrating nona(D-arginine) residues, to deliver siRNAs into oral cancer cells and induce silencing of the therapeutic target, CIP2A, an oncoprotein overexpressed in various human malignancies including oral cancer. Increasing the 599 peptide-to-siRNA molar ratio demonstrated a higher binding capacity for siRNA molecules and enhanced siRNA delivery into the cytoplasm of oral cancer cells. In fact, quantitative measurements of siRNA delivery into cells demonstrated that a 50∶1 peptide-to-siRNA molar ratio could deliver 18-fold higher amounts of siRNAs compared to cells treated with siRNA alone with no significant long-term cytotoxic effects. Most importantly, the 599 peptide-mediated siRNA delivery promoted significant CIP2A mRNA and protein silencing which resulted in decreased oral cancer cell invasiveness and anchorage-independent growth. Together, these data demonstrate that a chimeric peptide consisting of a fusogenic sequence, in combination with cell-penetrating residues, can be used to effectively deliver siRNAs into oral cancer cells and induce the silencing of its target gene, potentially offering a new therapeutic strategy in combating oral cancer.

Multidisciplinary clinic care improves adherence to best practice in head and neck cancer

PURPOSE

Multidisciplinary team (MDT) care is widely accepted as best practice for patients with head and neck cancer, although there is little evidence that MDT care improves head and neck cancer related outcomes. This study aims to determine the impact of MDT care on measurable clinical quality indicators (CQIs) associated with improved patient outcomes.

MATERIALS AND METHODS

Patients treated for head and neck cancer at Ipswich Hospital from 2001 to 2008 were identified. Comparisons were made in adherence to CQIs between patients treated before (pre MDT) and after (post MDT) the introduction of the MDT. Associations were tested using the Chi-square and Whitney U-test.

RESULTS

Treatment post MDT was associated with greater adherence to CQIs than pre MDT. Post MDT had higher rates of: dental assessment (59% versus 22%, p<.0001), nutritional assessment (57% versus 39%, p=.015), PET staging (41% versus 2%, p<.0001), chemo-radiotherapy (CRT) for locally advanced disease (66% versus 16%, p<.0001) and use of adjuvant CRT for high risk disease (49% versus 16%, p<.0001). The interval between surgery and radiotherapy was shorter in the post MDT group (p=.009) as was the mean length of hospitalization (p=.002).

CONCLUSIONS

This study highlights the measurable advantages of MDT care over the standard, less formalized, referral process.

Total glossectomy with laryngeal preservation and free flap reconstruction: objective functional outcomes and systematic review of the literature

OBJECTIVE

Advanced tongue cancer is a devastating diagnosis with potential for significant morbidity after treatment. This is especially true for patients undergoing total glossectomy with laryngeal preservation (TGLP), free flap reconstruction and adjuvant radiotherapy. The goals of this study were to: 1) determine long-term objective functional and quality of life outcomes, 2) investigate the influence of rehabilitation on functional recovery and 3) determine swallowing ability in patients with TGLP.

STUDY DESIGN

Prospective cohort study and systematic review of the literature.

METHODS

Functional outcomes data were collected from 2000-2010. Outcomes were measured pre- and 12 months post-surgery and included: gastrostomy-tube (G-Tube) rates, swallowing transit times on video fluoroscopic swallowing studies, speech intelligibility and EORTC-H&N 35 quality of life scores. A systematic review of the literature was conducted to determine comprehensive long term G-Tube rates.

RESULTS

Twelve patients were included and eight were still living at 12 months post-surgery. Fifty percent of patients in this study and 24% with systematic review used G-Tubes at 1 year post-surgery. Patients who could swallow did not aspirate, but more than doubled swallowing transit times. Spoken sentence intelligibility averaged 66% and mean quality of life scores improved 8.9 points 12 months post-surgery. Patients who attended >80% of swallowing and speech rehabilitation sessions demonstrated superior swallowing and speech functional outcomes.

CONCLUSIONS

Although a potentially morbid treatment, TGLP and free flap reconstruction can provide good swallowing and speech outcomes as well as meaningful long-term quality of life. Regular attendance of rehabilitation sessions is imperative to optimize functional outcomes.

Bax expression measured by AQUAnalysis is an independent prognostic marker in oral squamous cell carcinoma

Background

Resistance to apoptosis is a hallmark of cancer and proteins regulating apoptosis have been proposed as prognostic markers in several malignancies. However, the prognostic impact of apoptotic markers has not been consistently demonstrated in oral squamous cell carcinoma (OSCC). This inconsistency in reported associations between apoptotic proteins and prognosis can be partly attributed to the intrinsic low resolution and misclassification associated with manual, semi-quantitative methods of biomarker expression measurement. The aim of this study was to examine the association between apoptosis-regulating proteins and clinical outcomes in oral squamous cell carcinoma (OSCC) using the quantitative fluorescence immunohistochemistry (IHC) based AQUAnalysis technique.

Methods

Sixty-nine OSCC patients diagnosed between 1998–2005 in Calgary, Alberta, Canada were included in the study. Clinical data were obtained from the Alberta Cancer Registry and chart review. Tissue microarrays (TMAs) were assembled from triplicate cores of formalin-fixed paraffin embedded pre-treatment tumour tissue. Bax, Bcl-2 and Bcl-XL protein expression was quantified using fluorescent IHC and AQUA technology in normal oral cavity squamous epithelium (OCSE) and OSCC tumour samples. Survival was analyzed using Kaplan-Meier plots and the Cox proportional hazard model.

Results

Bax expression was predominantly nuclear in OCSE and almost exclusively cytoplasmic in OSCC. No similar differences in localization were observed for Bcl-2 or Bcl-XL. Only Bax expression associated with disease-specific survival (DSS), with 5-year survival estimates of 85.7% for high Bax versus 50.3% for low Bax (p = 0.006), in univariate analysis. High Bax expression was also significantly associated with elevated Ki67 expression, indicating that increased proliferation might lead to an improved response to radiotherapy in patients with elevated Bax expression. In multivariate analyses, Bax protein expression remained an independent predictor of DSS in OSCC [HR 0.241 (0.078-0.745), p = 0.013].

Conclusions

The AQUA technique used in our study eliminates observer bias and provides reliable and reproducible estimates for biomarker expression. AQUA also provides essential measures of quality control that cannot be achieved with manual biomarker scoring techniques. Our results support the use of Bax protein expression as a prognostic marker in conjunction with other clinico-pathological variables when designing personalized treatment strategies for OSCC patients.

Oral squamous cell carcinoma: clinicopathological features in patients with and without recurrence

AIM

To compare the clinicopathological profile of oral squamous cell carcinoma (OSCC) in groups with and without recurrence.

METHODS

Records of all patients who underwent surgery for primary OSCC at a single institution during 1999 were identified. Patient demographics, lesion site, clinical and pathologic stage, pathologic grading, pattern of invasion, lymphocytic infiltrate, perineural invasion, and treatment and survival data were collected. Descriptive statistics were calculated for each variable and survival was calculated using Kaplan-Meier and Cox models. Patients were divided into 2 groups: with (n = 25) and without (n = 28) recurrence.

RESULTS

Tongue (p = 0.02) and poorly differentiated (p = 0.04) tumors were associated with recurrence. Kaplan-Meier and Cox models revealed tobacco use and the absence of lymphocytic infiltrate to be associated with the poorest survival in recurrent OSCC.

CONCLUSION

The tumor site, tobacco use, and pathological features were involved in the recurrence of OSCC and should be taken into account for OSCC treatment and follow-up.

CIP2A expression and localization in oral carcinoma and dysplasia

AIMS

Oral squamous cell carcinoma (OSCC) is the most prevalent malignancy of the oral cavity resulting in severe morbidity and mortality. To date only few proteins have been suggested as potential biomarkers or targets for this type of cancer. Cancerous inhibitor of PP2A (CIP2A) is a protein expressed in epithelial tissues that stabilizes the oncogene c-Myc and causes cell transformation. This study was designed to investigate the expression of CIP2A in OSCC cell lines and tissues representing human normal, dysplasia and OSCC.

METHODS

Using quantitative real time PCR, mRNA quantification for CIP2A was performed in a primary gingival cell line and OSCCs CAL 27 and SCC-25. Paraffin embedded human specimen classified as normal, dysplastic or OSCC were immunohistochemically stained for CIP2A expression. EGFR and CIP2A were also stained by immunofluorescence for co-localization. Samples of human normal oral tissue and OSCC were studied by PCR for mRNA expression of CIP2A.

RESULTS

CIP2A was significantly increased in the human carcinoma cell lines compared to the primary gingival cell line. CIP2A was overexpressed in the human oral dysplasia and OSCC tissues compared to normal oral tissues. CIP2A was also preferentially localized in the dysplastic and OSCC epithelial areas compared to EGFR that was expressed mainly in areas of relatively normal epithelium and in dysplastic tissues above the basal layers.

CONCLUSIONS

CIP2A may play a significant role in oral malignant transformation and therefore, it may be a potential target for chemotherapy of OSCC.

Nodal yield and survival in oral squamous cancer: Defining the standard of care

BACKGROUND

Elective neck dissection (END) is commonly used as a staging and therapeutic procedure for oral squamous cell carcinoma (SCC) at high risk of nodal metastases. The authors aimed to determine whether the extent of lymphadenectomy, as defined by nodal yield, is a prognostic factor in this setting.

METHODS

A retrospective database review identified 225 patients undergoing END with curative intent for oral SCC between 1987 and 2009. Nodal yield was studied as a categorical variable for association with overall, disease-specific, and disease-free survival in univariate and multivariate analyses.

RESULTS

Nodal yield <18 was associated with 5-year overall survival of 51% compared with 74% in those with nodal yield ≥ 18 (P = .009). Five-year disease-specific survival rates were 69% in those with <18 nodes and 87% in patients with ≥ 18 nodes (P = .022). Similar results were obtained for disease-free survival, with 5-year rates of 44% with <18 nodes versus 71% with ≥ 18 nodes (P = .043). After adjusting for the effect of age, nodal status, T stage, and adjuvant radiotherapy on multivariate analysis, nodal yield <18 was associated with reduced overall (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.1-3.6; P = .020), disease-specific (HR, 2.2; 95% CI, 1.1-4.5; P = .043), and disease-free survival (HR, 1.7; 95% CI, 1.1-2.8; P = .040). In the pathologically lymph node-negative subgroup (n = 148), similar results were obtained.

CONCLUSIONS

Nodal yield is an independent prognostic factor in patients undergoing END for oral SCC. These results suggest that an adequate lymphadenectomy in this setting should include at least 18 nodes.

Lymph node ratio as an independent prognostic factor in oral squamous cell carcinoma

BACKGROUND

We aimed to validate the lymph node ratio (LNR) as an independent prognostic factor in oral squamous cell carcinoma (OSCC) and compare its utility with the current nodal staging system.

METHODS

We conducted a retrospective analysis of 313 patients with OSCC undergoing neck dissection. The LNR was adjusted by relevant covariates in a multivariable Cox regression model.

RESULTS

LNR displaced conventional nodal staging and was shown to be an independent predictor of regional failure (p = .020), disease-specific (p = .003) and overall survival (p = .001). Patients with an LNR of 2.5% to 7.5%, 7.5% to 20%, and >20% had 2.6, 3.7, and 4.4 times the risk of death from OSCC, respectively, when compared with patients with an LNR <2.5%.

CONCLUSIONS

The LNR is an independent prognostic factor in OSCC and may be used in conjunction with the current TNM staging to enable better risk stratification and selection for adjuvant therapy.