Oral epithelial dysplasia and squamous cell carcinoma following allogeneic hematopoietic stem cell transplantation: clinical presentation and treatment outcomes

Late Presentation of Oral Chronic Graft Versus Host Disease Manifesting As Hyperkeratotic Plaque: A Case Report

Hematopoietic stem cell transplantation is the only curative intervention for myelodysplastic syndrome, with graft-versus-host disease (GVHD) being a frequently encountered consequence. GVHD is classified as acute (aGVHD) or chronic (cGVHD). The oral cavity is the most impacted by chronic. Oral manifestations of cGVHD are variable and include plaque, Wickham striae, and lichenoid patches. In order to prevent malignant misdiagnosis, the 2014 NIH consensus report decided to exclude white plaque as a diagnostic indicator for oral cGVHD. Nevertheless, it is still possible to classify a white plaque lesion as cGVHD through histological confirmation. The performance of a biopsy should be undertaken following meticulous consideration and a thorough evaluation of the associated risks and benefits. The in-depth review of oral cancer risk assessment is crucial, necessitating a careful review of multiple factors to accurately estimate the likelihood of malignant transformation in individuals with oral cGVHD. This report describes a case of oral cGVHD manifesting as hyperkeratotic plaque lesions confirmed by histopathology in a 62-year-old man who received an allogeneic hematopoietic stem cell transplant over a decade ago.

Oral squamous cell carcinoma arising from areas of Graft-versus-host disease: A systematic review

BACKGROUND

Graft-versus-host disease (GVHD) is an immune system reaction that occurs in patients with a history of hematopoietic stem cell transplantation (HSCT), in which the grafted donor's cells attack those of the host. The objective of this systematic review was to present a study on oral squamous cell carcinoma (OSSC) that developed from GVHD areas in patients undergoing HSCT.

MATERIAL AND METHODS

An electronic search was conducted in the databases PUBMED, WEB OF SCIENCE, SCOPUS, MEDLINE and SCIENCE DIRECT, according to PRISMA guidelines.

RESULTS

Of the 1582 results, 23 articles were included, resulting in 81 cases. The most common underlying disease for performing the transplant was Myeloid Leukemia (55.6%). The mean age was 39 years, with a predilection for males (64.2%). The tongue was the site of GVHD that most frequently underwent transformation to SCC (59.3%). The average time between transplantation and the development of GVHD was of approximately of 8 months, while the average period of development between transplantation and the development of OSCC was of approximately of 111 months. The most common treatment to GVHD was cyclosporine associated with corticosteroids.

CONCLUSIONS

OSCCs arising from areas of GVHD present a different evolution from conventional oral carcinomas, since they affect younger patients, smoking and alcohol are not important etiological factors and finally because they present good prognosis, but further studies with larger number cases followed are needed to confirm our findings.

Perspectives on oral chronic graft-versus-host disease from immunobiology to morbid diagnoses

Chronic Graft-versus-Host Disease (cGVHD) is a major long-term complication, associated with morbidity and mortality in patients following allogenic hematopoietic cell transplantation (HCT) for immune hematopoietic disorders. The mouth is one of the most frequently affected organs after HCT (45-83%) and oral cGVHD, which may appear as the first visible sign. Manifestations present with mucosal lichenoid lesions, salivary gland dysfunction and limited oral aperture. Diagnosis of oral cGVHD severity is based on mucosal lesions with symptoms of sensitivity and pain and reduced oral intake. However, diagnostic difficulties arise due to subjective definitions and low specificity to cover the spectrum of oral cGVHD. In recent years there have been significant improvements in our understanding of the underlying oral cGVHD disease mechanisms. Drawing upon the current knowledge on the pathophysiology and biological phases of oral cGVHD, we address oral mucosa lichenoid and Sjogren's Syndrome-like sicca syndromes. We consider the response of alloreactive T-cells and macrophages to recipient tissues to drive the pathophysiological reactions and biological phases of acute inflammation (phase 1), chronic inflammation and dysregulated immunity (phase 2), and subsequent aberrant fibrotic healing (phase 3), which in time may be associated with an increased malignant transformation rate. When formulating treatment strategies, the pathophysiological spectrum of cGVHD is patient dependent and not every patient may progress chronologically through the biological stages. As such there remains a need to address and clarify personalized diagnostics and management to improve treatment descriptions. Within this review, we highlight the current state of the art knowledge on oral cGVHD pathophysiology and biological phases. We address knowledge gaps of oral cGVHD, with a view to facilitate clinical management and improve research quality on lichenoid biology and morbid forms of oral cGVHD.

Is Systemic Immunosuppression a Risk Factor for Oral Cancer? A Systematic Review and Meta-Analysis

Even if the relationship between immunosuppression and increased incidence of systemic cancers is well known, there is less awareness about the risk of developing oral cancer in immunosuppressed patients. The aim of this review was to evaluate the association between immunosuppression and the development of oral cancer. Two authors independently and, in duplicate, conducted a systematic literature review of international journals and electronic databases (MEDLINE via OVID, Scopus, and Web of Science) from their inception to 28 April 2023. The assessment of risk of bias and overall quality of evidence was performed using the Newcastle-Ottawa Scale and GRADE system. A total of 2843 articles was identified, of which 44 met the inclusion criteria and were included in either the qualitative or quantitative analysis. The methodological quality of the included studies was generally high or moderate. The quantitative analysis of the studies revealed that immunosuppression should be considered a risk factor for the development of oral cancer, with a percentage of increased risk ranging from 0.2% to 1% (95% CI: 0.2% to 1.4%). In conclusion, the results suggest that a constant and accurate follow-up should be reserved for all immunosuppressed patients as a crucial strategy to intercept lesions that have an increased potential to evolve into oral cancer.

Repeated Occurrence and Recurrence of Secondary Oral Solid Cancers after Hematopoietic Stem Cell Transplantation for Leukaemia: Long-Term Follow-Up

Hematopoietic stem cell transplantation (HSCT) is a common method for patients such as hematologic malignancies. However, HSCT generally has a higher risk of secondary solid cancer development. The aim of this study was to emphasize the need for lifelong follow-up of oral secondary solid cancer. The patient was a male who underwent HSCT for chronic myelogenous leukaemia at the age of 31 years. He underwent ten onsets on oral secondary solid cancers during his subsequent follow-up of more than 20 years. In conclusion, patients after HSCT require lifelong observation of oral secondary solid cancer, which may be accompanied by repeated new and recurrent occurrences.

Oral Epithelial Dysplasia: A Review of Diagnostic Criteria for Anatomic Pathologists

Oral epithelial dysplasia (OED) represents a spectrum of histologic changes in the oral cavity mucosa that has the potential to transform into oral squamous cell carcinoma. Predicting the risk of malignant transformation is predominantly based on clinicopathologic correlation, histologic examination and grading. OED often poses a diagnostic challenge, primarily due to its histologic mimics and a large number of terminologies used in the literature. The grading system for OED is also fraught with significant interobserver variability. This review summarizes the essential clinical and histopathologic features of OED and its mimics. Practical preanalytical, analytical, and postanalytical considerations for anatomic pathologists are discussed to improve the diagnostic accuracy and increase the reproducibility in the grading of OED.

Risk of oral cancer in patients with graft-vs-host disease: A systematic review and meta-analysis

OBJECTIVE

This systematic review was undertaken to determine the risk of oral cancer in patients with chronic graft-vs-host disease (cGvHD).

STUDY DESIGN

The search was conducted in 6 electronic databases (PubMed/MEDLINE, EMBASE, LILACS, Web of Science, Scopus, and LIVIVO) and gray literature (Google Scholar, Open Gray, and ProQuest) for studies published up to November 2021.

RESULTS

Of the 13 cohorts included in qualitative synthesis, 9 were eligible for the quantitative analysis. The meta-analysis showed that the presence of cGvHD increased the risk of developing oral cancer (risk ratio [RR] = 2.78; 95% CI, 1.27-6.08; I² = 46%; P = .01). A subgroup meta-analysis revealed a higher risk of oral cancer in Asian samples exposed to cGvHD (RR = 2.50; 95% CI, 1.54-4.04; I² = 0%; P = .0002), which was not seen in the pooled analysis of European samples (P = .24). The overall methodological quality of most studies included was "good." The cumulative evidence (Grading of Recommendations Assessment, Development and Evaluation) was considered moderate and of very low confidence for Asian and European studies, respectively.

CONCLUSIONS

Patients with cGvHD resulting from allogenic hematopoietic stem cell transplantation run an increased risk of developing oral cancer. Hence, it is recommended that patients with cGvHD be monitored to allow for the early detection and treatment of secondary malignant disease.

Oral Chronic Graft-Versus-Host Disease

Chronic oral graft-versus-host disease (cGVHD) is a complex, frequent, and highly impactful complication of allogeneic hematopoietic cell transplantation (alloHCT). It represents the leading cause of morbidity and mortality in long-term alloHCT survivors. cGVHD can affect almost any visceral organ system and commonly affects the skin, eyes and mouth, manifesting with signs and symptoms similar to other known immune-mediated and autoimmune diseases. Oral manifestations of GVHD include inflammation, thinning, and ulceration of oral mucosal tissues (similar to lichen planus), lymphocyte-mediated salivary gland dysfunction (similar to Sjögren/Sicca Syndrome), and decreased oral opening (trismus) secondary to sclerosis of oral and perioral tissues (analogous to limitation in scleroderma). Potential sequelae include severe mucosal pain, compromised nutrition, weight loss, limitation in opening, and sometimes irreversible fibrosis of the salivary glands. While some cases can be managed with topical therapies, management may also require long-term targeted immunosuppressive and/or corticosteroid therapy with associated risk of local and systemic infection, hyperglycemia, kidney dysfunction, osteopenia/osteoporosis, and possibly secondary malignancies. The aim of this mini-review is to provide an up-to-date review of literature related to the diagnosis and management of oral cGVHD to aid dental and medical clinicians in optimizing oral cGVHD therapy while minimizing potential adverse effects.

Secondary Oral Cancer after Systemic Treatment of Hematological Malignancies and Oral GVHD: A Systematic Review

Simple Summary

The number of hematopoietic cells transplantations is increasing annually, and the average survival time after treatment is gradually extending. As a result, these patients experience late side effects of hematological treatment, including secondary oral cancer. The oral cavity is relatively easily accessible for examination; therefore, every physician should be familiar with different pathologies of this area and, when necessary, refer patients to an ENT specialist for examination. In this review, the authors tried to identify a potential correlation between the oral chronic form of graft-versus-host disease and oral cancer in patients after hematopoietic cell transplantation, and they tried to propose a surveillance protocol and tips that can be used during a patient’s follow-up.

Abstract

(1) Purpose: In this article, the authors decided to systematically review the available literature to identify potential correlations regarding secondary oral carcinoma occurring after hematological systemic treatment and oral chronic graft-versus-host disease. (2) Methods: Medline (PubMed) and Scopus (Elsevier) databases were searched, including articles from the years 2002–2022. The 33 unique results were assessed by a PRISMA flowchart, and we rejected 24 papers and included 9 articles in the review. (3) Results: The majority of patients suffered from the oral form of chronic graft-versus-host disease before the diagnosis of oral malignancy. Two common cancer sites were the tongue and buccal mucosa. The exact percentage of secondary oral carcinoma after hematopoietic stem cell transplantation could not be estimated due to a lack of data. (4) Conclusions: Every physician taking part in the follow-up of patients after hematological treatment should be aware of the possibility of secondary neoplastic disease in the oral cavity, especially in patients with oral graft-versus-host disease. Proper follow-up protocols and monitoring are needed in this patient group as the cause of these cancers appears to be multifactorial.

Multifocal oral squamous cell carcinoma post haematopoietic stem cell transplantation: A case report

Oral squamous cell carcinoma is considered a rare complication of post-haematopoietic stem cell transplantation (HSCT). Early detection of these lesions is further complicated by the overlapping clinical appearance and presentation of lesions associated with chronic graft versus host disease (cGVHD). We report a case of oral squamous cell carcinoma in a 33 year-old man who presented with severe intraoral pain on the lower left side of the cheek and jaw 19 months after undergoing HSCT for the treatment of underlying acute lymphoblastic leukaemia. He was previously treated with intravenous cyclophosphamide as a conditioning regimen for HSCT and later developed cGVHD of the liver, eyes, and gut, which resolved with treatment. Intraoral examination revealed two separate lesions. The first lesion presented as a raised oval nodular swelling with a well-circumscribed margin and irregular surface on the left buccal mucosa. A similar, but more extensive, lesion was noted on the left lingual gingiva and was associated with spontaneous bleeding. Biopsy revealed that both lesions were well-differentiated squamous cell carcinomas and were p16 positive. He underwent palliative radiotherapy but succumbed to his disease 3 months after initiation of treatment.

Management of oral leukoplakia in patients with Fanconi anemia

Fanconi anemia (FA) is a rare genetic disease involving an increased risk of developing acute myeloid leukemia and solid tumors, especially head-and-neck squamous cell carcinomas, for which the oral cavity is the most frequent site of occurrence. The patient presented in this study underwent allogeneic hematopoietic stem cell transplantation (HSCT) and developed nonhomogeneous oral leukoplakia after 7 years, which was promptly removed and diagnosed with high-grade epithelial dysplasia. Many risk conditions for oral squamous cell carcinoma were featured in the present case including FA, allogeneic HSCT, graft-versus-host disease, immunosuppressive therapy, female gender, nonsmoker, tongue location and nonhomogeneous type of leukoplakia. Close follow-up of the entire upper aerodigestive tract mucosa and early removal of all suspected lesions are highly recommended in the management of such patients.

Oral chronic GVHD after allogeneic stem cell transplantation without total body irradiation performed at a young age

Purpose

Long-term survivors (LTSs) of allogeneic hematopoietic stem cell transplantation (allo-HCT) may experience oral long-term effects like chronic graft-versus-host disease (oral cGVHD). The aim of this study was to investigate oral cGVHD in patients treated at a young age (< 30 years) more than 5 years after allo-HCT without total body irradiation (TBI).

Methods

All 94 participants went through a semi-structured interview, and an oral examination. Diagnosis of oral cGVHD was based on the “National Institutes of Health (NIH) cGVHD diagnosis and staging consensus criteria” from 2014.

Results

Mean age at transplantation was 17.5 years (range 0.4–29.9 years), and mean time since transplantation was 16.7 years (range 6–26 years). Oral cGVHD was diagnosed in 26 (28%) of 94 LTSs. Of which 20 (21.5%) showed lichen planus-like (LPL) changes, and additionally six (6.5%) also fulfilled the diagnostic criteria of oral cGVHD since they had one or more distinctive signs and symptoms of oral cGVHD combined with definite cGVHD in another organ. No LTSs reported oral cGVHD (NIH) grade 3. There was a significant association between cGVHD in the oral cavity and cGVHD in another organ (77% vs 29%, p < 0.001). Out of 72 LTSs, who answered the questions regarding taste disturbances, 16 (22%) reported dysgeusia. No LTSs developed secondary malignancies in the oral cavity during follow-up time.

Conclusion

Oral long-term effects, such as oral cGVHD, may persist for many years after allo-HCT without TBI-conditioning in patients treated at a young age.

Two Lip Carcinomas following Allogeneic Hematopoietic Stem Cell Transplantation: A Case Report and Literature Review

Background

Secondary solid cancers are severe complications in patients who have undergone allogeneic hematopoietic stem cell transplantation (AHSCT) for malignant and nonmalignant lymphohematopoietic diseases.

Objective

The aim of this work was to report a case of two lip carcinomas following AHSCT and to warn doctors about the importance of regular check-ups of patients who have received HSCT. Observation. A 57-year-old man was referred by the dermatology department for the management of exophytic budding lesions on the lower lip evolving since 5 months. The patient was in complete remission following allogeneic bone marrow transplantation for acute myeloid leukemia since five years. Clinical and histological findings confirmed the diagnosis of a squamous cell carcinoma of the two lesions.

Conclusion

It is of paramount importance to seek an oral squamous cell carcinoma in the presence of persistent lesions in HSCT recipients.

Management of Oral Potentially Malignant Disorders

Patients with oral potentially malignant disorders (OPMDs), including oral leukoplakia and erythroplakia, proliferative verrucous leukoplakia, oral submucous fibrosis, and oral lichen planus/lichenoid lesions can be challenging to manage. A small proportion will undergo cancer development and determining a patient's cancer risk is key to making management decisions. Yet, our understanding of the natural history of OPMDs has not been fully elucidated, and a precision approach based on the integration of numerous predictive markers has not been validated by prospective studies. Evidence-based health promotion by clinicians and healthcare systems is not embraced universally. Medical and surgical interventions evaluated by rigorous research measuring important endpoints, such as cancer development, mortality, or survival are difficult and expensive to run. Most of these studies employ non-ideal surrogate endpoints and have deep methodologic flaws. Diagnostic criteria for enrolling research subjects are not uniform, and patients with the highest risk for cancer development comprise small proportions of those enrolled. Few studies explore quality of life and patient preferences. It is time to rethink how we approach the management of these patients, across each OPMD, and considering the healthcare infrastructure and cost effectiveness. Global networks with well-characterized patient populations with OPMDs and well-designed interventional trials using validated outcome measures are needed.

Oral white lesion in patients post-hematopoietic stem cell transplantation: a case series demonstrating the diagnostic dilemma

The current National Institutes of Health (NIH) consensus paper excluded "white hyperkeratotic plaque" from the diagnostic criteria for oral chronic graft-versus-host disease (cGVHD) in order to ensure malignant transformation is not overlooked. Therefore, an isolated oral white plaque is recommended to be subjected to biopsy and pathologic examination. The cases described in this paper shed a new light on the clinical approach to oral white plaque post-hematopoietic stem cell transplantation. The objectives of this article are to demonstrate that a white plaque does not contradict a diagnosis of oral cGVHD, and to highlight the clinical considerations for taking a biopsy.

P16-positive secondary tongue squamous cell carcinoma following allogeneic hematopoietic stem cell transplantation: A case report and literature review

As a method to improve the survival rate of patients with hematological malignancies, allogeneic hematopoietic stem cell transplantation (allo-HSCT) has increasingly been used for treatment. However, some potentially serious complications after allo-HSCT, including graft-versus-host disease, graft failure, infection, end-organ toxicity, and secondary malignancies, will determine the success of hematopoietic reconstitution. Here, we describe a case of a patient with p16-positive tongue squamous cell carcinoma (TSCC) following allo-HSCT. A 62-year-old man who had previously received allo-HSCT due to acute lymphocytic leukemia (AML) presented with erosions on the back of the tongue surrounded by multiple white patches, which were compatible with oral chronic graft-versus-host disease (cGVHD). During follow-up, a circular-like erosive lesion appeared on the right dorsal surface of the tongue. Biopsy of this lesion confirmed early invasive TSCC (T2N0M0). Partial glossectomy and tongue reconstruction were performed after cessation of immunosuppressants. Immunohistochemical (IHC) staining was positive for p16 and ki-67, suggesting a probable active human papillomavirus (HPV) infection. Six months after surgery, the patient showed no signs of metastasis or recurrence nor progression of oral GVHD.

Secondary oral cancer following hematopoietic cell transplantation

The aim of this retrospective study was to determine the incidence and the clinical outcome of secondary oral cancer (SOC) and to assess potential risk factors in a large cohort of patients (n = 908), who received allogeneic hemopoietic cell transplantation (HCT) either for a malignant (n = 733) or nonmalignant hematologic disease (n = 175). The median follow-up of 438 transplant survivors was 17 years. Twelve patients developed SOC at a median of 13.5 years since HCT and at a median age of 47 years. The 35-year cumulative incidence function of SOC development was 3.47%. In univariate analysis, factors associated with increased incidence of SOC were reduced intensity conditioning and chronic graft-versus-host disease (cGvHD). On multivariate analysis, nonmalignant disease and duration of oral cGvHD ≥15 months were independent risk factors for SOC development. Nonmalignant disease recipients had 3.94× higher than expected rate of SOC (95% confidence interval, 1.50-10.39%, p = 0.0055). Recipients whose oral cGvHD persisted for more than ≥15 months had 58.6× higher than expected rate of SOC (95% confidence interval, 13.3-258.1%), p < 0.0001). This study demonstrates that oral cGvHD and a diagnosis of nonmalignant hematologic disease are strong risk factors in the SOC development.

Oral chronic graft-versus-host disease: What the general dental practitioner needs to know

BACKGROUND

Long-term survivors of allogeneic hematopoietic cell transplantation will increasingly seek care from dental providers.

METHODS

The authors highlight the importance of minimizing oral symptoms and complications associated with oral chronic graft-versus-host-disease (cGVHD).

RESULTS

Chronic GVHD is the result of an immune response of donor-derived cells against recipient tissues. Oral cGVHD can affect the mucosa and damage salivary glands and cause sclerotic changes. Symptoms include sensitivity and pain, dry mouth, taste changes, and limited mouth opening. Risk of developing caries and oral cancer is increased. Food intake, oral hygiene, and dental interventions can represent challenges. Oral cGVHD manifestations and dental interventions should be managed in close consultation with the medical team, as systemic treatment for cGVHD can have implications for dental management.

CONCLUSIONS

General dental practitioners can contribute substantially to alleviating oral cGVHD involvement and preventing additional oral health deterioration.

PRACTICAL IMPLICATIONS

Frequent examinations, patient education, oral hygiene reinforcement, dry mouth management, caries prevention, and management of dental needs are indicated. In addition, oral physical therapy might be needed. Invasive dental interventions should be coordinated with the transplantation team. Screening for oral malignancies is important even years after resolution of GVHD symptoms. Management of the oral manifestations of cGVHD might require referral to an oral medicine professional.

Oral potentially malignant disorders: A consensus report from an international seminar on nomenclature and classification, convened by the WHO Collaborating Centre for Oral Cancer

Oral potentially malignant disorders (OPMDs) are associated with an increased risk of occurrence of cancers of the lip or oral cavity. This paper presents an updated report on the nomenclature and the classification of OPMDs, based predominantly on their clinical features, following discussions by an expert group at a workshop held by the World Health Organization (WHO) Collaborating Centre for Oral Cancer in the UK. The first workshop held in London in 2005 considered a wide spectrum of disorders under the term "potentially malignant disorders of the oral mucosa" (PMD) (now referred to as oral potentially malignant disorders: OPMD) including leukoplakia, erythroplakia, proliferative verrucous leukoplakia, oral lichen planus, oral submucous fibrosis, palatal lesions in reverse smokers, lupus erythematosus, epidermolysis bullosa, and dyskeratosis congenita. Any new evidence published in the intervening period was considered to make essential changes to the 2007 classification. In the current update, most entities were retained with minor changes to their definition. There is sufficient evidence for an increased risk of oral cancer among patients diagnosed with "oral lichenoid lesions" and among those diagnosed with oral manifestations of 'chronic graft-versus-host disease'. These have now been added to the list of OPMDs. There is, to date, insufficient evidence concerning the malignant potential of chronic hyperplastic candidosis and of oral exophytic verrucous hyperplasia to consider these conditions as OPMDs. Furthermore, due to lack of clear evidence of an OPMD in epidermolysis bullosa this was moved to the category with limited evidence. We recommend the establishment of a global research consortium to further study the natural history of OPMDs based on the classification and nomenclature proposed here. This will require multi-center longitudinal studies with uniform diagnostic criteria to improve the identification and cancer risk stratification of patients with OPMDs, link them to evidence-based interventions, with a goal to facilitate the prevention and management of lip and oral cavity cancer.

In situ buccal carcinoma in a teenager after hematopoietic stem cell transplantation: A case report

RATIONALE

Hematopoietic stem cell transplantation (HSCT) is the most effective treatment for the majority of patients who have malignant haemolytic disease. Although the success rate of HSCT has increased, the increasing number of cases suffering from secondary solid malignancies after HSCT has attracted more interest recently.

PATIENT CONCERNS

A 16-year-old female patient from China presented with a crusty and painful lesion on the left buccal mucosa with a history of chronic graft-versus-host disease following allogeneic HSCT for acute myeloid leukaemia.

DIAGNOSIS

An incisional biopsy of the lesion showed stratified squamous epithelium mucosa with severe dysplasia (carcinoma in situ). Subsequently, a wide local excision was performed and histological examination revealed early infiltrating squamous epithelial mucosa (carcinoma in situ).

INTERVENTIONS

She was being treated in the oral and maxillofacial surgery clinic with an incisional biopsy of the left buccal mucosa. She also received a wide local excision.

OUTCOMES

Follow-up for 4 years showed no recurrence.

LESSONS

This case helps raise awareness of the diagnosis of oral symptoms in young patients after HSCT. Due to the increasing application of HSCT, raising awareness in oral and dental physicians may be required to improve long-term clinical outcome of patients who underwent HSCT.

Oral Dysplastic Complications after HSCT: Single Case Series of Multidisciplinary Evaluation of 80 Patients

Oral squamous cell carcinoma (OSCC) is the most common secondary solid malignancy after hematopoietic stem-cell transplantation (HSCT). OSCC following HSCT is frequently preceded by chronic graft-versus-host disease (cGVHD). The aim of this study was to describe a cohort of post-HSCT patients and to evaluate the onset of oral epithelial dysplasia and/or OSCC over time. In this retrospective cohort study, we present a cohort of hematological patients that underwent HSCT. Demographic variables, clinical hematological data, data regarding acute graft-versus-host disease (aGVHD) and cGVHD, and oral clinical features were analyzed. We focused on clinicopathological features of a subgroup of 22 patients with oral cGVHD and OSCC after HSCT. Among 80 included patients, 46 patients (57.5%) developed aGVHD and 39 patients (48.7%) developed cGVHD. Oral mucosa was involved in 17 patients with aGVHD (36.9%) and in 22 patients (56.4%) with cGVHD. Out of a total of 22 oral biopsies, roughly 40% revealed mild to moderate dysplasia, and 32% were OSCC. In the absence of international agreement on the best timing of oral follow-up after HSCT, it is mandatory to establish a close multidisciplinary evaluation in order to prevent the onset of HSCT-related OSCC and to reduce post-transplant mortality due to secondary tumors.

Oral Potentially Malignant Disorders and Oral Cavity Cancer

The Surveillance, Epidemiology, and End Results program from the National Cancer Institute reports that the aggregate number of oral cavity and pharyngeal cancer cases has been increasing over the past decade and, despite an overall decline in oral cavity cancers, this increase is largely related to a dramatic increase in cancers involving oropharyngeal subsites. Early detection of oral cavity cancers is commensurate with improved survival, and opportunistic screening by trained clinicians to detect oral cavity cancer and oral potentially malignant disorders is recommended by the American Dental Association and the American Academy of Oral Medicine.

Adverse Drug Events in the Oral Cavity

Adverse reactions to medications are common and may have a variety of clinical presentations in the oral cavity. Targeted therapies and new biologic agents have revolutionized the treatment of cancers, autoimmune diseases, and inflammatory and rheumatologic diseases but have also been associated with adverse events in the oral cavity. This review describes the most common clinical presentations of oral mucosal reactions to medications, namely hyposalivation, lichenoid reactions, ulcers, bullous disorders, pigmentation, fibrovascular hyperplasia, reactive keratosis, dysesthesia, osteonecrosis, infection, angioedema, and malignancy.

[Oral complications following allogeneic hematopoietic cell transplantation: Recommendations of the Francophone Society of Bone Marrow transplantation and cellular Therapy (SFGM-TC)]

Stomatological complications of allogeneic hematopoietic stem cell transplantation (HSCT) are frequent and very uncomfortable for patients. The primary complication is the graft versus host disease reaction. Other side effects of the procedure include infections, taste disorders and carcinogenic risks. Various local treatments are used but remain imperfect. Within the framework of the 10th workshop of practice harmonization of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) held in Lille in September 2019, diagnostic approaches and treatments of tongue and oral complications following allogeneic HSCT were reviewed according to the analysis of published studies.

Secondary Squamous Cell Carcinoma of the Tongue Complicated with Bronchiolitis Obliterans as a Manifestation of Graft-versus-Host Disease following Peripheral Blood Stem Cell Transplantation

Peripheral blood stem cell transplantation (PBSCT) has increasingly been used for hematologic cancer therapy, resulting in improved survival rates. However, risks include graft-versus-host disease (GVHD) and secondary solid tumors. Here, we describe a case of tongue squamous cell carcinoma (SCC) complicated by bronchiolitis obliterans (BO) following PBSCT. A 42-year-old man with a history of acute lymphocytic leukemia treated with PBSCT presented with multiple white lesions and erosions on the tongue and buccal mucosa that are compatible with oral chronic GVHD (NIH criteria: score 2). The lesions were presented for 8 years. The patient had a history of BO manifested as GVHD. During follow-up, an exophytic mass was rapidly developed on the left dorsum of the tongue. Biopsy of this lesion confirmed SCC (cT2N0M0). Pulmonary function testing for general anesthesia was almost normal. Hemiglossectomy, supraomohyoid neck dissection, and tongue reconstruction were performed. Thirteen months after surgery, the patient showed neither recurrence of tumor nor progression of oral GVHD. However, the patient died of respiratory failure due to repeated pneumothoraxes and deterioration of BO.

HPV-related oral dysplasia in a multiple myeloma patient after stem cell transplantation

The development of dysplastic changes in oral epithelial lesions is a potential long-term complication after hematopoietic stem cell transplantation (HSCT). This may be related to mechanisms including radiation and chemotherapy regimens, chronic graft-versus-host disease (cGVHD), inflammation, and prolonged immunosuppression. The current case describes a 54-year-old male with multiple myeloma treated by autologous and allogenic HSCT followed by development of cGVHD (mouth, skin and the eyes) with the complaint of diffuse white lesions on the buccal mucosa, tongue, and palate. A biopsy performed with histopathological analysis revealed moderate to severe epithelial dysplasia with hyperkeratosis, positive for p16INK4A as a surrogate marker for human papillomavirus (HPV). Our finding suggests a possible association of oral dysplasia and HPV in patients after receiving allogenic HSCT with the necessity of more clinical follow-ups for those patients that may be at a higher risk for the development of oral dysplasia associated with HPV.

Clinicopathologic characteristics of secondary squamous cell carcinoma of head and neck in survivors of allogeneic hematopoietic stem cell transplantation for hematologic malignancies

The risk of late complications including secondary malignancies is increased in long-term survivors of allogeneic hematopoietic stem cell transplants (HSCT). There is limited literature on the biological behavior and clinical features of squamous cell carcinoma (SCC) of head and neck post-HSCT. We present the clinical and pathologic characteristics on six patients who were diagnosed with SCC while in remission following an allogeneic HSCT. Median follow-up was 8 years. Five patients (83%) developed SCC of tongue and one developed esophageal SCC. Five patients had oral chronic graft-versus-host disease (cGvHD). The conventional risk factors of alcohol, tobacco, and human papillomavirus were absent. The most common presenting finding was the new-onset focal oral pain and ulcerated plaques clinically indistinguishable from a flare of their oral cGvHD lesions. We demonstrated that the SCC in three patients was of donor origin.

Oral health and dental morbidity in long-term allogeneic blood and marrow transplant survivors in Australia

BACKGROUND

Oral and dental disease is a major cause of long-term morbidity following allogeneic blood and marrow transplantation (Allo-BMT). This study aimed to describe the extent and range of oral and dental complications in BMT recipients and to identify gaps in service provision provided to this high-risk group.

METHODS

Participants were Allo-BMT recipients, aged >18 years, and received transplants between 2000 and 2012 in NSW. They completed seven surveys, the purpose-designed Sydney Post-BMT Study survey and six other validated instruments.

RESULTS

Of 441 respondents, many reported dry mouth (45.1%), dental caries (36.7%), mouth ulcers (35.3%), oral GVHD (35.1%), gingivitis (16.2%), tooth abscess (6.1%) and oral cancer (1.5%). Regular dental visits were reported by 66.2% of survivors. Middle-high income, older age and geographic location showed a positive association with regular dental visits. Of those who did not visit the dentist regularly, 37% stated they did not feel it necessary, 36% reported cost and 20% stated it was not advised by the treating team.

CONCLUSION

Despite oral complications commonly occurring after Allo-BMT, many survivors receive inadequate dental care. These results emphasize the need for improved oral health education, the importance of regular dental checks and improvement in the delivery of dental health services for BMT survivors.

Clinical features and presentation of oral potentially malignant disorders

Oral potentially malignant disorders (OPMDs) are conditions that precede the onset of invasive cancers of the oral cavity. The term embraces precancerous lesions and conditions referred to in earlier World Health Organization (WHO) definitions. Leukoplakia is the most common OPMD; erythroplakia, although rare, is more serious. Several variants of leukoplakia are recognized, and clinical subtyping may help determine the prognosis to a limited extent. Biopsy is essential to confirm the provisional clinical diagnosis, and timely referral to a specialist is indicated. Certain OPMDs, such as oral submucous fibrosis, are encountered particularly in population groups from Asia with specific lifestyle habits. This review provides clinical descriptions of the wide range of potentially malignant disorders encountered in the oral cavity as a prelude to the topics discussed in this focus issue.

Risk Stratification of Oral Potentially Malignant Disorders in Fanconi Anemia Patients Using Autofluorescence Imaging and Cytology-On-A Chip Assay

Fanconi anemia (FA) is a hereditary genomic instability disorder with a predisposition to leukemia and oral squamous cell carcinomas (OSCCs). Hematopoietic stem cell transplantation (HSCT) facilitates cure of bone marrow failure and leukemia and thus extends life expectancy in FA patients; however, survival of hematologic malignancies increases the risk of OSCC in these patients. We developed a "cytology-on-a-chip" (COC)-based brush biopsy assay for monitoring patients with oral potentially malignant disorders (OPMDs). Using this COC assay, we measured and correlated the cellular morphometry and Minichromosome Maintenance Complex Component 2 (MCM2) expression levels in brush biopsy samples of FA patients' OPMD with clinical risk indicators such as loss of autofluorescence (LOF), HSCT status, and mutational profiles identified by next-generation sequencing. Statistically significant differences were found in several cytology measurements based on high-risk indicators such as LOF-positive and HSCT-positive status, including greater variation in cell area and chromatin distribution, higher MCM2 expression levels, and greater numbers of white blood cells and cells with enlarged nuclei. Higher OPMD risk scores were associated with differences in the frequency of nuclear aberrations and differed based on LOF and HSCT statuses. We identified mutation of FAT1 gene in five and NOTCH-2 and TP53 genes in two cases of FA patients' OPMD. The high-risk OPMD of a non-FA patient harbored FAT1, CASP8, and TP63 mutations. Use of COC assay in combination with visualization of LOF holds promise for the early diagnosis of high-risk OPMD. These minimally invasive diagnostic tools are valuable for long-term surveillance of OSCC in FA patients and avoidance of unwarranted scalpel biopsies.

Rationale for neoadjuvant immunotherapy in head and neck squamous cell carcinoma

The clinical benefit of immunotherapy in recurrent, metastatic head and neck squamous cell carcinoma has fueled interest in revisiting neoadjuvant approaches to complement definitive treatment. Neoadjuvant strategies incorporating immune checkpoint inhibitors and other novel immune-based therapies in head and neck cancer are reviewed here, with particular attention paid to the rationale for these approaches from both a clinical and biologic discovery standpoint. The potential benefits of neoadjuvant immunotherapy include reduction of extent of surgery and the intensity of adjuvant therapy by tumor downstaging, reduction of the risk of distant metastatic spread by early introduction of systemic therapy, conversion of unresectable to resectable disease, and early evaluation of biomarkers of tumor response. We await early trial results utilizing these approaches to confirm both safety and initial efficacy in head and neck cancer.