Squamous carcinoma of the tongue: review

Assessment of Dysphagia after Hemiglossectomy and Radiotherapy: A Prospective Study

Background Malignancy of the tongue is a common condition affecting patients and their day-to-day activities. The tongue plays an important role in deglutition. The combination treatment modality involving surgical resection with or without reconstruction and radiation is the most commonly used modality for such lesions. This in turn has a profound impact on the quality of life of the patients owing to the nature of the treatment.

Aim of the study This study aimed to assess swallowing in patients with carcinoma tongue following hemiglossectomy and radiotherapy (RT).

Methodology A prospective study carried out in 20 patients who underwent hemiglossectomy with primary closure for carcinoma of the tongue followed by RT. All patients were evaluated for swallowing using the Dysphagia Handicap Index before surgery; after surgery on the 10th and 30th days; during RT after 15 fractions of radiation; and after 1, 2, and 3 months postcompletion of RT.

Results The Dysphagia Handicap Index has significantly increased from the preoperative value following both surgery and RT on all follow-up visits (p < 0.001). The most severe self-reported dysphagia was noted during and after RT(p < 0.001).

Conclusion This study shows that hemiglossectomy followed by primary closure with adjuvant RT has a severe negative impact on swallowing, thereby affecting the quality of life.

Assessment of Speech in Patients Undergoing Hemiglossectomy with Primary Closure and Radiotherapy - A Prospective Study

Introduction

The oral cavity plays a pivotal role in the generation of speech. The treatment of oral squamous cell carcinoma of the tongue requires an aggressive approach, combining resective surgery along with radiation therapy, with long-lasting effects on the patient's ability to speak. This study was designed to assess speech in subjects with carcinoma of the tongue following hemiglossectomy with primary closure and radiotherapy.

Methods

A prospective study was carried out in 20 subjects who underwent hemiglossectomy with primary closure for carcinoma of the tongue followed by radiotherapy. All subjects were evaluated for speech using 'Kannada Diagnostic Photo Articulation Test' before surgery, after surgery (on the 10th and 30th day), during radiation therapy after 15 fractions of radiation and after 1, 2 and 3 months following completion of radiotherapy. Statistical analysis was performed using SPSS software (v. 17.0). Significance levels were determined using ANOVA followed by Bonferroni correction.

Results

Intelligibility of speech was noted to be affected most at the one month follow-up visit after completion of radiotherapy (P < 0.001). The Kannada Diagnostic Photo Articulation Test proves to be a useful tool in assessing changes in speech, with results that can be replicated in further studies.

Discussion

The incidence of articulatory errors is increased following surgery and radiotherapy. Over time, the number of errors reduce and approach the baseline, indicating that although speech is indeed hampered by the treatment, with adequate speech therapy one can regain their preoperative articulation.

Step-by-Step Cadaver Dissection and Surgical Technique for Compartmental Tongue and Floor of Mouth Resection

Background

The aim of oral cancer surgery is tumor removal within clear margins of healthy tissue: the latter definition in the literature, however, may vary between 1 and 2 cm, and should be intended in the three dimensions, which further complicates its precise measurement. Moreover, the biological behavior of tongue and floor of mouth cancer can be unpredictable and often eludes the previously mentioned safe surgical margins concept due to the complexity of tongue anatomy, the intricated arrangements of its intrinsic and extrinsic muscle fibers, and the presence of rich neurovascular and lymphatic networks within it. These structures may act as specific pathways of loco-regional tumor spread, allowing the neoplasm to escape beyond its visible macroscopic boundaries. Based on this concept, in the past two decades, compartmental surgery (CS) for treatment of oral tongue and floor of mouth cancer was proposed as an alternative to more traditional transoral resections.

Methods

The authors performed three anatomical dissections on fresh-frozen cadaver heads that were injected with red and blue-stained silicon. All procedures were documented by photographs taken with a professional reflex digital camera.

Results

One of these step-by-step cadaver dissections is herein reported, detailing the pivotal points of CS with the aim to share this procedure at benefit of the youngest surgeons.

Conclusions

We herein present the CS step-by-step technique to highlight its potential in improving loco-regional control by checking all possible routes of tumor spread. Correct identification of the anatomical space between tumor and nodes (T-N tract), spatial relationships of extrinsic tongue muscles, as well as neurovascular bundles of the floor of mouth, are depicted to improve knowledge of this complex anatomical area.

From Bench to Bedside in Tongue Muscle Cancer Invasion and Back again: Gross Anatomy, Microanatomy, Surgical Treatments and Basic Research

Tongue squamous cell carcinoma is the most common malignancy in the oral cavity. Despite advances in diagnosis and treatment, the prognosis of advanced states has not significantly improved. Depth of invasion, pattern of invasion such as tumor budding grade, lingual lymph node metastasis in early stages, collective cell migration and circulating tumor cells in peripheral blood are some examples of the mechanisms that are currently receiving increasing attention in the evaluation of the prognosis of tongue cancers. Anatomic-based surgery showed that it is possible to improve loco-regional control of tongue cancer. In patients with a "T-N tract involvement", there is significantly more distant recurrence (40%) in patients undergoing a compartmental tongue surgery. In general, the neoplastic infiltration of the lingual muscles is traced back to the finding of neoplastic tissue along the course of a muscle; however, the muscle fibers, due to their spatial conformation and the organization of the extracellular matrix, could influence the movement of tumor cells through the muscle, leaving its three-dimensional structure unchanged. We need to exclude the possibility that tongue muscle fibers represent a mechanism for the diffusion of cancer cells without muscle invasion.

Application of chimerical ALT perforator flap with vastus lateralis muscle mass for the reconstruction of oral and submandibular defects after radical resection of tongue carcinoma: a retrospective cohort study

BACKGROUND

Patients with tongue carcinoma who undergo combined tongue and neck radical resection often have simultaneous oral and submandibular defects. Due to its high flexibility, the anterolateral thigh (ALT) perforator flap is gradually being adopted by surgeons for oral reconstruction. However, the tissue volume of perforator flaps is insufficient for the reconstruction of both the oral and submandibular regions. In this retrospective cohort study, we compared the postoperative outcomes and complications between patients reconstructed with using the classical ALT perforator flap and patients reconstructed using the chimeric ALT perforator flap with vastus lateralis muscle mass.

METHODS

From August 2017 to August 2019, 25 patients underwent reconstructive therapy using a classical ALT perforator flap (classical group), while 26 patients were reconstructed with the chimeric ALT perforator flap (chimeric group) after radical resection of tongue cancer in Xiangya Hospital, Central South University. The flap survival rate, incidence of submandibular infection, lateral appearance, lower extremity function, and quality of life were compared between the two groups.

RESULTS

There were no differences in flap survival rate and postoperative lower extremity function between the two groups. The incidence of submandibular infection was 15.4 and 40% in the chimeric and classical group, respectively. The duration of recovery was 12.20 ± 2.69 and 15.67 ± 4.09 days in the chimeric and classical group, respectively. The submandibular region fullness was satisfactory in the chimeric group. The postoperative quality of life in the chimeric group was better than that in the classical group (P < 0.05).

CONCLUSIONS

The chimerical ALT perforator flap with muscle mass reconstructs both the oral and submandibular defects accurately. It maintains the profile and fullness of the submandibular region and may reduce the incidence of submandibular infection.

Classification of GLOSSECTOMIES: Proposal for tongue cancer resections

Background

Surgery of tongue tumors includes different procedures ranging from mucosal resection to complex combined resection. Numerous terms have been used to describe such procedures, but there is no consensus between the terminology and the extent of resection.

Methods and Results

We searched the medical literature and found a lack of published information. We undertook to describe a new classification of surgical procedures for tongue tumor resection. We based it upon the surgical anatomy of the tongue and the spread of the cancer. We posited that there were five major types of glossectomy embracing all the methods of tongue cancer resection. This classification was reviewed and endorsed by an international team of experts.

Conclusion

We propose a more precise classification than that currently in practice, thereby bringing clarity and consistency to the terminology, facilitating shared communication between surgeons, comparison between published research, and ultimately improving surgical practice and patient care.

Compartmental surgery for oral tongue and floor of the mouth cancer: Oncologic outcomes

BACKGROUND

Oral tongue/floor of mouth squamous cell carcinoma (OTFMSCC) with a depth of invasion (DOI) > 10 mm involves extrinsic muscles and lingual neurovascular/lymphatic bundles. "Compartmental" hemiglossopelvectomy (CHGP) was developed to improve loco-regional control by "en bloc" removal of tumor and its pathways of spread.

METHODS

We conducted a retrospective observational study on 45 CHGPs performed at a single institution for OTFMSCC with a DOI > 10 mm at CT/MR. Group A (n = 35) included naïve patients, and group B (n = 10) recurrent cancers. We evaluated 2-year overall survival (OS), disease-free survival (DFS), local control (LC), and loco-regional control (LRC).

RESULTS

Two-year OS, DFS, LC, and LRC were 80%, 91%, 100%, and 94% for group A, and 27%, 26%, 67%, and 36% for group B, respectively. Salvage surgery and positive margins were significantly associated with worse prognosis.

CONCLUSION

CHGP is a reliable oncologic approach in primary surgery for advanced OTFMSCC. In recurrent cancers, survival remains poor.

Besides and Beyond Histopathology; for Adjuvant Treatment in Early Tongue Cancer

Oral tongue squamous cell carcinomas differ significantly from that of other subsites of oral cavity in relation to clinical behavior. They are more aggressive and have a poorer prognosis. The treatment of choice of early (stage I and II) tongue cancers is surgery. The need for adjuvant treatment is decided on the basis of the histopathology report of the surgical specimen. High-risk patients (positive surgical margins, perineural invasion, lymphovascular spread, lymph node metastasis, and extracapsular extension) receive adjuvant treatment while others are observed. Unfortunately, in the apparently low-risk patients who are observed, there is a high rate of locoregional failure. There are certain histopathology parameters though not routinely validated may be of prognostic significance in this subset of patients. In this review, we have highlighted the importance of the routinely validated and the nonvalidated histopathology parameters and their proper assessment in the decision-making for adjuvant treatment of patients with early tongue cancers.

Cancer Stem Cells in Oral Cavity Squamous Cell Carcinoma: A Review

Cancer stem cells (CSCs) have been identified in oral cavity squamous cell carcinoma (OCSCC). CSCs possess the ability for perpetual self-renewal and proliferation, producing downstream progenitor cells and cancer cells that drive tumor growth. Studies of many cancer types including OCSCC have identified CSCs using specific markers, but it is still unclear as to where in the stem cell hierarchy these markers fall. This is compounded further by the presence of multiple CSC subtypes within OCSCC, making investigation reliant on the use of multiple markers. This review examines the current knowledge in CSC markers OCT4, SOX2, NANOG, ALDH1, phosphorylated STAT3, CD44, CD24, CD133, and Musashi-1, specifically focusing on their use and validity in OCSCC CSC research and how they may be organized into the CSC hierarchy. OCSCC CSCs also express components of the renin–angiotensin system (RAS), which suggests CSCs may be novel therapeutic targets by modulation of the RAS using existing medications.

Elective neck dissection in unilateral carcinomas of the tongue: Unilateral versus bilateral approach

PURPOSE

Elective neck dissection (END) is a common primary treatment strategy for oral tongue squamous cell carcinoma (OTSCC), although uncertainty remains regarding the necessary extent of END for strictly unilateral early stage OTSCC. The authors evaluated two END variations, unilateral and bilateral, to determine the optimal extent.

MATERIALS AND METHODS

A retrospective cohort study was performed on patient data from two departments of oral and maxillofacial surgery. All previously untreated patients from both clinics who were diagnosed with early-stage (pT1-2) unilateral OTSCC were included. The following variables were collected: age, gender, END type/extent, tumor localization, later nodal metastasis, and TNM status. Statistical analyses were performed (p < 0.05).

RESULTS

A total of 150 patients were identified, 105 receiving unilateral END and 45 bilateral END. The rates of postoperative positive lymph nodes were 21.9% for ipsilateral END and 26.7% for bilateral END (bilateral END: all positive nodes ipsilateral). In all, 14 patients in the ipsilateral group developed nodal metastasis during tumor aftercare (11 patients ipsilateral, 3 patients contralateral neck). In the bilateral group, nodal metastasis was later observed in 4 cases (8.9%; 3 cases ipsilateral, 1 case contralateral neck). Statistical analysis could not detect significant differences between the END procedures.

CONCLUSION

As both procedures lead to similar results in preventing or omitting possible later nodal metastasis, the two methods seem to be valuable alternatives. In conclusion, we recommend bilateral END because of advantages with regard to oncologic safety and esthetic outcome, but the decision for END should always be according to the patient's general health status, comorbidities, and individual tumor risk profile.

A new surgical strategy for treatment of tongue squamous cell carcinoma based on anatomic study with preliminary clinical evaluation

BACKGROUND

This study characterized the infiltration of primary tumors along the intrinsic and extrinsic muscles of the tongue in oral tongue squamous cell carcinoma (OTSCC), to create a new surgical strategy that is suitable for most stages. A preliminary evaluation of this novel surgical approach was also conducted.

METHODS

An anatomic study of macroscopic specimens from 10 human cadavers and 100 OTSCC patients was conducted. The anatomic characteristics of the primary tumors and the origin and distribution of fibers of the intrinsic and extrinsic tongue muscles were observed and measured. After initial treatment with curative intent, the 100 patients were regularly followed-up with clinical examination and imaging.

RESULT

Based on the anatomic characteristics of the primary tumors and tongue muscles, a new surgical approach was developed, and was described as muscle anatomy tongue surgery (MATS). MATS proved suitable for almost all stages of OTSCC. According to the morphology of the invasive tumor front, the 100 cases were divided into four types. The rate of 2-year local disease control was 98%, locoregional control 86%, disease-free survival 85%, and overall survival 89%. Tongue functions were perfectly recovered in more than 60% of the patients.

CONCLUSION

Application of the principles of MATS to the treatment of OTSCC proved suitable for almost all stages of the disease. MATS is a novel surgical technique that may improve outcomes in tongue cancer surgery.

Relationship between appearance of tongue carcinoma on intraoral ultrasonography and histopathologic findings

OBJECTIVE

To clarify whether intraoral ultrasonography (I-US) is effective for predicting metastasis of tongue cancer to the cervical lymph nodes.

STUDY DESIGN

Participants comprised 29 patients with tongue carcinoma classified as T1-T4 using the TNM staging system. All patients underwent I-US preoperatively. Postoperatively, resected specimens were evaluated histopathologically.

RESULTS

I-US found that cases with invasive depth ≥3 mm had higher potential for cervical lymph node metastasis than those with invasive depth <3 mm (P < .05). No other significant relationships were identified between observations on I-US and cervical lymph node metastasis. Cases with histopathologic blood vessel infiltration or lymph duct infiltration had a significant difference in risk of cervical lymph node metastasis.

CONCLUSIONS

I-US is useful for preoperatively assessing the invasive depth of tongue carcinoma. Furthermore, observations from I-US and invasive depth of the tumor allowed presumptive diagnosis with regard to cervical lymph node metastasis.

Expression of fatty acid binding protein 4 is involved in the cell growth of oral squamous cell carcinoma

Fatty acid binding proteins (FABPs) are a family of small and highly conserved lipid chaperone molecules with highly varied functions. Among them, fatty acid binding protein 4 (FABP4, also known as aP2) is highly expressed by adipocytes, macrophages and dendritic cells. Although the role of FABP4 in cancer is still unclear, it has been reported to be highly expressed by human tumors such as ovarian and bladder cancers. In the present study, we investigated the expression and role of FABP4 in oral squamous cell carcinoma (SCC) and its expression in oral SCC tissues. Immunohistochemical staining revealed that FABP4 expression in the tumor tissue was much higher than that in the non-tumor area of the same specimen. In the in vitro studies, an FABP4-knockdown SCC cell line (established through FABP4-specific siRNA) showed inhibited growth, and inhibited expression and activation of mitogen-activated protein kinase (MAPK). These results indicate that expression of FABP4 plays an important role in the cell growth of oral SCC through the MAPK pathway.

From wide excision to a compartmental approach in tongue tumors: what is going on?

PURPOSE OF REVIEW

Surgical approaches to tongue cancer have not changed substantially over the years. The literature proposes some indications for tumor excision even though type of intervention, resection margins, neck dissection, and 'en bloc' resection versus separate excision of tumor and lymph nodes do not seem to be standardized. The purpose of this review is to describe the evolution of surgical management of tongue carcinoma with particular attention to recent reports focusing on compartmental tongue surgery.

RECENT FINDINGS

The current literature usually describes resection of tongue carcinoma within wide disease-free margins, ranging from 1.5 to 2 cm. In case of advanced-stage tumors, performing concomitant neck dissection is recommended; otherwise, a deferred neck dissection is indicated if depth of neoplastic infiltration exceeds 4 mm. In recent years, a new technical approach has been formulated based on anatomy of the tongue, thus, introducing the concept of an anatomy-based, function sparing, compartmental surgery.

SUMMARY

Applying such a proposal to clinical practice aims at standardizing a surgical procedure that otherwise might be arbitrary. Compartmental surgery improves overall survival, does not seem to worsen functional outcomes of the residual tongue, and allows comparison of case studies.

Electron beam radiotherapy for tongue cancer using an intra-oral cone

To explain the adaptation technique using an intra-oral cone (IOC) for radiation therapy, and to determine the optimal schedule resulting in a high local control rate and an acceptable complication rate using direct electron beam radiation for the treatment of tongue cancer. Thirty patients with the tongue cancer (T1:T2:T3=16:11:3) were treated with 6-15 MeV electron radiation using an IOC. Twenty-six patients were treated with electron radiation using an IOC with or without an excisional biopsy. The other four patients were treated with a combination of the external beam radiation and electron radiation using the IOC. In order to formulate a safe and effective treatment program, we calculated the biologically effective dose (BED). The two- and five-year local control rates for all patients were 63% and 52%, respectively. The two- and five-year overall survival rates for all patients were 73% and 69%, respectively. Local control was achieved in 12 of 15 patients who were irradiated with a BED of 90.9 Gy(10) or more, whereas it was not achieved in nine of the 15 patients who were treated with less than a BED of 90.9 Gy(10) (p=0.03). The application of electron radiation using an IOC for the treatment of tongue cancer provides acceptable local control and adverse effect rates, especially for elderly patients considered to be high risk for complications from anesthesia. The optimum BED(10) value for the treatment of early tongue cancer using the IOC technique appears to be at least 90.9 Gy(10).

Molecular and cellular regulatory mechanisms of tongue myogenesis

The tongue exerts crucial functions in our daily life. However, we know very little about the regulatory mechanisms of mammalian tongue development. In this review, we summarize recent findings of the molecular and cellular mechanisms that control tissue-tissue interactions during tongue morphogenesis. Specifically, cranial neural crest cells (CNCC) lead the initiation of tongue bud formation and contribute to the interstitial connective tissue, which ultimately compartmentalizes tongue muscles and serves as their attachments. Occipital somite-derived cells migrate into the tongue primordium and give rise to muscle cells in the tongue. The intimate relationship between CNCC- and mesoderm-derived cells, as well as growth and transcription factors that have been shown to be crucial for tongue myogenesis, clearly indicate that tissue-tissue interactions play an important role in regulating tongue morphogenesis.

Role of endothelin receptor signalling in squamous cell carcinoma

Endothelin plays important roles in various physiological functions including vascular constriction. Recent studies reported that the endothelin receptors ETA and ETB are highly expressed in lung and skin tumor tissues. In contrast, there are few reports on endothelin signalling in the proliferation of head and neck cancer. We found that both ETA and ETB endothelin receptors were overexpressed in tumor cells of tongue cancer samples by immunohistochemistry. ETA and ETB were expressed in cultured lingual and esophageal squamous cell carcinoma (SCCs) cell lines. When both cultured cell lines were treated with an ETA selective antagonist (BQ123) or an ETB selective antagonist (BQ788), inhibition of cell growth was observed. Similar results were observed when SCCs were treated with specific siRNA for the suppression of ETA or ETB. Furthermore, inhibition of the mitogen-activated protein (MAP) kinase pathway by the treatments with ET receptor antagonists and siRNA was also observed. These results indicate that endothelin signalling may, in part, play important roles in cell growth in SCCs through the MAP kinase pathway.

Modern surgical management of tongue carcinoma - a clinical retrospective research over a 12 years period

Objectives

In this retrospective study, we present a clinical review of our experience with tongue cancer in order to obtain valid criteria for therapeutic decision-making.

Materials and methods

Between August 1999 and June 2011, a total of 398 patients with squamous cell carcinoma of the tongue were treated at the Department of Oral and Maxillofacial Surgery, King Edward Medical University Lahore Pakistan. Data concerning patient characteristics, clinical and pathologic tumour characteristics and treatment strategies and their results were obtained from a retrospective review of medical records. The average follow-up was 4.6 years. Statistical analysis for survival was calculated by the method of Kaplan and Meier.

Results

There were 398 total patients. The mean age at diagnosis was 49.5 years,. 224 (56.3%) were male and 174 (43.7%) female (male/female ratio = 1.3:1).332/398 patients received surgical treatment, whereas 66 patients were excluded from surgical treatment and received primary radio (chemo) therapy after biopsy. Tongue carcinoma patients treated by non surgical treatment modalities had 5 years survival rate of 45.5% and patients with surgical intervention had survival rate of 96.1%.

Conclusions

We recommend categorical bilateral neck dissection in order to reliably remove occult lymph node metastases. Adjuvant treatment modalities should be applied more frequently in controlled clinical trials and should generally be implemented in cases with unclear margins and lymphatic spread.

Clinical relevance

This study provides modern treatment strategies for the tongue carcinoma.

Electroporation therapy for T1 and T2 oral tongue cancer

CONCLUSION

Electroporation therapy appears to be a safe treatment achieving excellent local tumor control and very good functional results in our study and it should be further clinically evaluated.

OBJECTIVES

The objectives of this study were to assess local tumor control, survival, and effects on speech and eating after treatment of tongue cancer with electroporation therapy, a new local therapeutic modality. In this approach intracellular accumulation of a chemotherapeutic agent is achieved by using a locally applied electrical field.

METHODS

Fifteen patients with primary T1 and T2 oral tongue cancer were treated with electroporation therapy with intratumorally administered bleomycin. Postoperative radiotherapy was performed when the tumor infiltration was 5 mm or more. The follow-up time was 24 months for the surviving patients and 20.4 months overall. The effects on eating and speech were assessed using the PSS-HN scale and voice recordings.

RESULTS

No local recurrence was recorded in any patient during the follow-up. Three patients died, two from progressive regional disease. Of the 12 surviving patients, 2 patients had regional recurrence and 10 patients including the 5 patients treated with EPT alone were tumor-free both locally and regionally at the last follow-up. The functional outcome for speech and eating were very good.

Compartmental tongue surgery: Long term oncologic results in the treatment of tongue cancer

Compartmental tongue surgery (CTS) is a surgical technique that removes the compartments (anatomo-functional units) containing the primary tumor, eliminating the disease and potential muscular, vascular, glandular and lymphatic pathways of spread and recurrence. Compartment boundaries are defined as each hemi-tongue bounded by the lingual septum, the stylohyoid ligament and muscle, and the mylohyoid muscle. In this non-randomized retrospective study we evaluated the oncologic efficacy of CTS in patients with squamous cell carcinoma (SCCA) of the tongue treated from 1995 to 2008. We evaluated 193 patients with primary, previously untreated cT2-4a, cN0, cN+, M0 SCCA with no contraindication to anesthesia and able to give informed consent. Fifty patients treated between October 1995 and July 1999 received standard surgery (resection margin >1cm); 143 patients treated between July 1999 and January 2008 received CTS. Study endpoints were: 5-year local disease-free, locoregional disease-free and overall survival. After 5years, local disease control was achieved in 88.4% of CTS patients (16.8% improvement on standard surgery); locoregional disease control in 83.5% (24.4% improvement) and overall survival was 70.7% (27.3% improvement). The markedly improved outcomes in CTS patients, compared to those treated by standard surgery, suggest CTS as an important new approach in the surgical management of tongue cancer.

Outcome of oral tongue squamous cell carcinoma in patients with and without known risk factors

BACKGROUND

Tobacco smoking and high alcohol consumption are considered major risk factors of oral tongue squamous cell carcinoma. This study compared disease outcome between patients with and without known risk factors.

METHODS

Patients with oral tongue squamous cell carcinoma treated at two major medical centers from 1994 to 2008 were identified by cancer registry search. The medical files were reviewed for background-and-disease-related data, risk factors, and outcome.

RESULTS

The study sample consisted of 291 patients: 175 had a history of heavy tobacco smoking and alcohol abuse and 116 did not. Comparison of the patients without risk factors between the two centers yielded no differences in background features. Men accounted for 74% of the total patients with risk factors and comprised 77% of the risk-factor group. The risk-factor group was characterized by a significantly higher mean tumor grade (p=0.0001) and greater tumor depth of invasion (p=0.022) than the non-risk-factor group. The 5-year local and regional control rates were 85.3% and 74%, respectively, with no significant difference between the groups. The 5-year overall survival rate was 68% in the risk-factor group and 64% in the non-risk-factor group (p=NS). Separate analysis of patients aged <40 years at diagnosis revealed a worse overall (p=0.015) and disease-free survival (p=0.038) in those without risk factors.

CONCLUSIONS

The outcome of oral tongue carcinoma is similar in patients with and without risk factors. The worse prognosis in younger patients (<40 years) without risk factors suggests that the pathogenesis in these cases involves factors other than smoking and alcohol.

Surgical resection for oral tongue cancer pulmonary metastases

The aim of this study was to evaluate the efficacy of surgical resection of oral tongue cancer (OTC) pulmonary metastases. Between 1977 and 2003, 23 OTC patients who developed 1-3 pulmonary metastases underwent metastasectomy. There were 14 men and nine women with a median age at the time of first metastasectomy of 56 years. All patients had advanced squamous cell OTC with synchronous or metachronous regional lymph node metastases. The median tumor-free interval after the last OTC treatment was 12 months. Five patients underwent pneumonectomy, three bilobectomy, 13 lobectomy, and two wedge resection. Two patients underwent a second pulmonary metastasectomy. One patient continues to survive, without recurrence 19 years after metastasectomy. Another patient was alive with disease at 24 months after metastasectomy but was lost to follow-up. Twenty-two out of 23 patients developed systemic metastases. The median interval to systemic recurrence after lung resection was 4.1 months, and 21 out of 23 patients died of OTC (median, 9.5 months) after metastasectomy. Most patients who underwent pulmonary metastasectomy died of the disease within two years of metastasectomy. Even for patients with a solitary metastasis, surgical metastasectomy is not a recommended treatment option.

The prognostic value of hypoxia markers in T2-staged oral tongue cancer

Tumor hypoxia is associated with poorer outcome in patients with head and neck carcinomas, but little is known about hypoxia biomarkers in oral tongue cancer. We evaluated whether hypoxia biomarkers and clinicopathologic variables were prognostic predictors in patients with T2-staged squamous cell carcinoma (SCC) of the oral tongue. Tissue microarrays were constructed from formalin-fixed tumor blocks of 43 patients with T2-staged tongue SCCs treated by surgical resection and neck dissection. Tissue samples were stained with monoclonal antibodies to hypoxia-inducible factor (HIF)-1alpha, HIF-2alpha, carbonic anhydrase (CA)-9, glucose transporter (GLUT)-1, and erythropoietin receptor (EPOR). Locoregional control and survival rates were calculated by the Kaplan-Meier method, and prognostic factors were calculated from uni- and multivariate analyses. Tumor thickness was correlated with expression of CA-9 and GLUT-1 and nodal classification was correlated with GLUT-1 expression. The nodal metastasis rate was 51%, and the 5-year locoregional control and disease-specific survival (DSS) rates were 59% and 69%, respectively. Univariate analysis showed that HIF-1alpha and EPOR expression were significantly related to DSS. Multivariate analysis showed that EPOR expression was an independent predictor of DSS (P=0.030). EPOR expression may be an independent predictor for DSS in patients with T2-staged SCC of the oral tongue.

Squamous cell carcinoma of the oral tongue: a 25-year, single institution experience

Aim:

To report the characteristics, prognostic factors and treatment outcomes of 102 patients with squamous cell carcinoma of the oral tongue treated and followed up at a single institution over a 25-year period.

Patients and methods:

This retrospective study was carried out by auditing the medical records of 102 patients diagnosed with squamous cell carcinoma of the oral tongue and treated at our institution between 1982 and 2007. Patient follow up ranged from nine to 310 months (median 35 months). Fifty per cent of the patients were treated with surgery followed by a combination of chemotherapy and radiotherapy (43.1 per cent received concurrent chemoradiation and 6.9 per cent received sequential chemotherapy and radiotherapy), whereas 29.4 per cent received surgery followed by adjuvant radiotherapy alone. The remaining patients (20.6 per cent) did not undergo surgery and were treated with definitive radiotherapy with or without chemotherapy.

Results:

There were 48 men and 54 women. The age at presentation was 19–85 years (median 57 years). The peak incidence was observed between 60 and 70 years. Resection margins were clear in 75 per cent of patients and involved in 25 per cent. Stage I disease was found in 11.8 per cent of patients, stage II in 34.3 per cent, stage III in 22.5 per cent and stage IV in 31.4 per cent. The five-year disease-free survival and overall survival were 65.7 and 72.5 per cent, respectively. Thirty-five patients suffered recurrence after treatment, 74.0 per cent of them at the site of initial cervical nodal involvement. Univariate analysis for overall survival revealed the following as prognostic factors: treatment schedule (surgical vs non-surgical; p < 0.001); age (<60 years vs ≥60 years; p = 0.038); extent of cervical lymph node involvement (p = 0.015); primary tumour stage (p < 0.001); node stage (p = 0.034); and disease stage (p = 0.013). However, on multivariate analysis, only non-surgical treatment (p = 0.001) and advanced disease stage (p = 0.05) were found to have a negative influence on survival.

Conclusions:

Our limited data suggest that, in Iran, squamous cell carcinoma of the oral tongue tends to present at a locally advanced stage, with a high frequency of locoregional failure and a poor outcome. Combined modality therapy should be considered for the majority of patients with squamous cell carcinoma of the tongue.

Poor prognosis in patients with stage I and II oral tongue squamous cell carcinoma

BACKGROUND

The objective of this study was to compare survival in patients with squamous cell carcinoma (SCC) of the oral tongue with that in patients with SCC in other oral cavity subsites.

METHODS

Patients with stage I and II (T1-T2N0M0) SCC of the oral cavity diagnosed between 1988 and 2004 were queried by using the Surveillance, Epidemiology, and End Results (SEER) database. The log-rank test was used to compare the overall survival (OS) and cause-specific survival (CSS) of patients who had oral tongue SCC with those of patients who had SCC of other oral cavity subsites. A Cox proportional hazards multivariate analysis was performed to evaluate the influence of covariates on the risk of CSS and OS.

RESULTS

Between 1988 and 2004, 6791 patients with stage I and II SCC of the oral cavity were identified. Among them, 40% had oral tongue SCC, and 60% had SCC of other oral cavity subsites. The median patient age was 64 years. The 5-year OS and CSS rates were 60.9% and 83.5%, respectively, for patients with oral tongue SCC versus 64.7% and 94.1%, respectively, for patients with SCC of other oral cavity subsites (OS: hazard ratio, 1.24; P< .0001; CSS: hazard ratio, 3.04; P< .0001). On multivariate analysis, OS and CSS were influenced significantly by T classification, age, sex, and oral tongue subsite. The CSS for patients who had stage I and II oral tongue SCC also was unfavorable compared with the CSS for stage-matched patients who had SCC of other head and neck sites.

CONCLUSIONS

Oral tongue SCC was associated with poor survival compared with other oral cavity and head and neck sites. These data suggested a potential benefit for multimodality therapy in this cohort of patients.

Critical role of estrogen receptor on anoikis and invasion of squamous cell carcinoma

Estrogen receptor (ER) plays an important role in various physiological functions. We examined whether ERalpha and ERbeta are expressed in squamous cell carcinoma (SCC), and whether ER is a potential target for antitumor therapy. High-level expression of ERbeta, but not ERalpha, was observed in tumor cells of human primary SCC tissues and various SCC cultured cell lines. Treatment with ER antagonist (tamoxifen), but not agonist (estradiol), caused apoptotic cell death of SCC cells in a concentration- and time-dependent manner. Adhesion of SCC was inhibited by the treatment with tamoxifen, but not with estradiol. Tamoxifen reduced the phosphorylation of focal adhesion kinase (FAK), resulting in decreases in phosphorylation of extracellular signal-related kinase (Erk) and mitogen-activated protein kinase. Inhibition of FAK phosphorylation is accompanied by disorder of the cytoskeletal component actin. The cell death caused by tamoxifen is therefore the result of direct interference in cell adhesion, which is called 'anoikis', involving a decrease in intracellular FAK signaling. Expression of epidermal growth factor receptor was also inhibited by treatment with a high concentration of tamoxifen. Knockdown of ERbeta by small interfering RNA inhibited the proliferation of SCC. In addition, tamoxifen strongly inhibited invasion of SCC. These results imply a potentially important role for ER, whose inhibition may be effective for the treatment of SCC and the prevention of invasion and metastasis.

Epidemiological analysis of tongue cancer in South Australia for the 24-year period, 1977-2001

BACKGROUND

Tongue cancer (141 ICD-9) is the most common intra-oral malignancy in Western countries. In recent decades, reported tongue cancer incidence and mortality rates have increased both in Europe and in the United States, whilst survival has not improved. This study aimed to determine the epidemiology and survival trends of tongue cancer in South Australia over the 24-year period from 1977 to 2001.

METHODS

Population-based data for tongue cancer were provided by the Central Cancer Registry Unit of the Epidemiology Branch of the South Australian Department of Health. Age-standardized incidence and mortality rates for males and females were calculated. Kaplan-Meier survival analysis was conducted according to time periods, age, sex and tongue sub-sites. Cox regression analysis was used to determine factors that influenced survival.

RESULTS

During this 24-year period, 611 cases of tongue cancer (398 males, 213 females) were reported, the majority of which were squamous cell carcinomas. The most common age of diagnosis was 65-69 years in males and 60-64 years in females. Fifty cases (8.18 per cent of all tongue cancer cases) occurred in patients 40 years or younger. The most common cancer sub-sites reported were 'unspecified site' (48.45 per cent), lateral border (25.53 per cent) and base (18.49 per cent) of the tongue. The age-standardized incidence and mortality rates for males and females in South Australia were relatively low and stable, and there was no significant improvement in survival of tongue cancer over this period. Significant predictors for survival were sex, age and tongue sub-sites, with male, advanced age and base of tongue associated with poorer survival.

CONCLUSIONS

Tongue cancer is an important health issue associated with poor survival. Early detection and diagnosis is important in order to improve survival rate for this malignancy.

Demographic, aetiological and survival differences of oral squamous cell carcinoma in the young and the old in Sri Lanka

Oral squamous cell carcinoma (OSCC) is a major oncological problem in many regions of the world where tobacco habits are practiced in the form of chewing and/or smoking with or without alcohol intake. It accounts for 16.5% of all cancers in Sri Lankan patients with a male:female ratio of 4:1. In Sri Lanka nearly 5% of OSCC are diagnosed in young patients. This comparative study describes, demographic, aetiological and survival data from young and old patients with OSCC (n=56). Both younger and older groups showed a marked male predilection (male:female ratio was 4:1 and 3.7:1 in younger and older groups respectively). Tongue was the commonest site for younger group (41%, P<0.01) whilst buccal mucosa (37.5%, P<0.05) and alveolar mucosa (25%, P<0.01) were for older group. 39% of cancers in younger group were not associated with any identifiable risk factor (P<0.01) and 70% of SCC of the tongue has no associated habits (P<0.01). SCC of the tongue in the younger group shows poor prognosis than the older patients. Three-year survival rate for the total number showed no significant difference in two age groups. Survival appeared to be better in patients without associated habits in the older group.

Diffuse expression of laminin gamma2 chain in disseminating and infiltrating cancer cells indicates a highly malignant state in advanced tongue cancer

The expression of laminin (LN)gamma2 chain in the primary lesions of 20 patients with advanced tongue cancer was analyzed. Positive expressions of LNgamma2 were noted in all of the primary tissue specimens, however, the expression patterns clearly differed according to the mode of growth and invasion of cancer cells. In tumor nests where cancer cells preserved cell-cell adhesiveness and showed polar differentiation, LNgamma2 was expressed only in the peripheral cells of the tumor nests; peripheral expression. On the other hands when cancer cells diminished their cell-cell adhesiveness and strongly infiltrated through stroma, almost all of the cancer cells diffusely expressed LNgamma2; diffuse expression. The peripheral expression of LNgamma2 were noted in 13 patients and the diffuse expressions were noted in 7 patients. The rates of positive cervical metastases according to the expression type were 7/13 for the peripheral expression and 7/7 for the diffuse expression (p = 0.02). The diseases specific 3-year survival rates for the patients with the peripheral expression and the diffuse expression were 68% and 14%, respectively (p = 0.02). The diffuse expression of LNgamma2 in the disseminating and infiltrating cancer cells might indicate a highly malignant state in advanced tongue cancer. Therefore, a more intensive treatment modality would be necessary for the patients with advanced tongue cancer showing the diffuse LNgamma2 expression.

Critical Role of Peroxisome Proliferator-Activated Receptor γ on Anoikis and Invasion of Squamous Cell Carcinoma

PURPOSE

Peroxisome proliferator-activated receptor gamma (PPARgamma) plays a important role in various physiological functions. We examined whether PPARgamma is expressed in primary squamous cell carcinoma and lymph node metastasis and whether PPARgamma is a potential target for tumor therapy.

EXPERIMENTAL DESIGN AND RESULTS

A high-level expression of PPARgamma was observed in tumor cells of human primary squamous cell carcinoma, lymph node metastasis, and squamous cell carcinoma cell lines. Treatment with PPARgamma-specific antagonists, but not agonists, caused apoptotic cell death on squamous cell carcinoma cell lines in a concentration-dependent manner. Small interfering RNA for PPARgamma also inhibited cell adhesion and growth of squamous cell carcinomas. The phosphorylation of focal adhesion kinase (FAK) was decreased by treatment with PPARgamma antagonists, and resulted in decreases in phosphorylation of Erk and mitogen-activated protein kinase. Furthermore, PPARgamma antagonists decreased the adhesion of squamous cell carcinomas into fibronectin-coated plates, indicating the inhibition of interaction between squamous cell carcinomas and fibronectin. Expression of integrin alpha5, a counter adhesion molecule for fibronectin, was inhibited by the treatment with PPARgamma antagonists. These results indicate that the decrease in integrin alpha5 and following inhibition of cell adhesion may cause the inhibition of FAK signaling pathways. PPARgamma antagonists also strongly inhibited invasion of squamous cell carcinoma via down-regulation of CD151 expression.

CONCLUSIONS

The cell death caused by the PPARgamma antagonists was a result of direct interference with cell adhesion "anoikis" involving intracellular FAK signaling pathways. These results imply a potentially important and novel role for the inhibition of PPARgamma function via the use of specific antagonists in the treatment of squamous cell carcinoma and the prevention of tumor invasion and metastasis.

Application of fuzzy inference to European patients to predict cervical lymph node metastasis in carcinoma of the tongue

In head and neck cancers, the presence of cervical lymph node metastasis is an important determinant of outcome. Many attempts have been made to predict cervical lymph node metastasis, but the accuracy of currently available techniques remains inadequate. We used fuzzy inference to predict cervical lymph node metastasis retrospectively in 75 patients with squamous cell carcinoma of the tongue and prospectively in 23 patients. Our model was based on three variables: tumor size, keratinization, and mode of invasion. The accuracy of fuzzy inference for the prediction of cervical lymph node metastasis in the 75 patients studied retrospectively was 86.7%, the sensitivity was 70.8%, and the specificity was 94.1%. In the 23 patients studied prospectively, the accuracy was 91.3%, the sensitivity was 50.0%, and the specificity was 95.2%. The accuracy obtained in this European series of patients was similar to that previously obtained in Japanese patients. We conclude that fuzzy inference may be a useful method for predicting cervical lymph node metastasis. Its high specificity is likely to reduce the number of unnecessary neck dissections. However, the current level sensitivity is inadequate for routine clinical use. Therefore, other predictors of lymph node metastasis should be identified to refine the current model.

Interaction between the immune system and tongue squamous cell carcinoma induced by 4-nitroquinoline N-oxide in mice

Squamous cell carcinoma of the oral cavity (SCC) accounts for 3% of cancers in the western world and 40% of cancers in India. The overall 5-year survival rate is only 50%. Most of the lesions appear intra-orally on the tongue. Results from a previous study demonstrated a significant increase in T and B-lymphocytes under the transformed epithelium when examining human lesions of hyperkeratosis, dysplasia and carcinoma of the tongue. In order to investigate the interaction between the host immunity and SCC, carcinogen induced SCC of the tongue was studied in mice. The water-soluble carcinogen, 4 nitroquinoline N-oxide (4NQO), was applied to BALB/c mice tongues and produced tongue SCC after a long incubation period of several months. Immunologic properties were examined systemically in the spleens and locally, at the tumor site. Examination of spleen lymphocytes from 4NQO induced mice revealed enlargement of the spleens and a significant decrease in the CD3, CD4, CD8 and CD19 cells. In the tongues, expression of TGF-beta, TNF-alpha, GM-CSF, and IL-1 beta mRNA were detected. TNF-alpha protein was detected in the affected tongues using immunoassays. mRNA expression of TNF-alpha was detected in the cancerous epithelium when extracted from the connective tissue. CD11b and CD3 cells were detected in the connective tissue under the developing carcinoma. CD11b positive cells were more prominent. The infiltrate was very scattered and not prominent as the infiltrate in the human tongue tissues. These results indicate that the growing tumor affected the immune response around the tumor and systemically. Most of the cytokines, which appeared in the affected tongues, originated from the tumor surroundings, but TNF-alpha was found also in the tumor. The interaction between the tumor and immune response components is important for diagnosis and treatment purposes.

Results of low- and high-dose-rate interstitial brachytherapy for T3 mobile tongue cancer

PURPOSE

To evaluate the treatment results of low-dose-rate (LDR) and high-dose-rate (HDR) interstitial brachytherapy (ISBT) for T3 mobile tongue cancer.

MATERIAL AND METHODS

Between 1974 and 1992, 61 patients with T3 mobile tongue cancer were treated with LDR ISBT using (192)Ir hairpins with or without single pins. In addition, between 1991 and 1999, 14 patients were treated with HDR ISBT. For nine patients treated with ISBT alone, the total dose was 59-94 Gy (median 72 Gy) within one week in LDR ISBT and 60 Gy/10 fractions/5 days in HDR ISBT. For 66 patients treated with a combination therapy of external beam radiotherapy (EBRT) and ISBT, the total dose was 12.5-60 Gy (median 30 Gy) of EBRT and 50-112 Gy (median 68 Gy) within 1 week in LDR ISBT or 32-60 Gy (median 48 Gy)/8-10 fractions/5-7 days in HDR ISBT.

RESULTS

The 2- and 3-year local control rates of all patients were both 68%. The 2- and 3-year local control rates of patients treated with LDR ISBT were both 67%, and those with HDR ISBT were both 71%. The local control rate of patients treated with HDR ISBT was similar to those with LDR ISBT.

CONCLUSIONS

ISBT for T3 mobile tongue cancer is effective and acceptable. The treatment result of HDR ISBT is almost similar to that of LDR ISBT for T3 mobile tongue cancer.

The clinical significance of follow-up sonography in the detection of cervical lymph node metastases in patients with stage I or II squamous cell carcinoma of the tongue

OBJECTIVE

We sought to assess the reliability of repeated sonography in the detection of cervical lymph node metastases at the earliest stage during a follow-up period in patients with stage I or stage II carcinoma of the tongue.

STUDY DESIGN

Eighteen consecutive patients with stage I or II squamous cell carcinoma of the tongue were included. When possible, every patient was examined with sonography approximately every 2 weeks during the follow-up period.

RESULTS

With repeated sonography on 18 patients, 7 metastatic nodes of 7 patients (39%) meeting our criteria were found. With the use of computed tomography, we diagnosed 10 nodes (including the 7 nodes observed with sonography) in these 7 patients as metastatic. A histopathologic examination revealed that 12 nodes in the same 7 patients had metastatic foci. For sonography, the sensitivity per node was 58%, whereas that of computed tomography was 83%.

CONCLUSIONS

Follow-up sonography enabled the detection of all patients who had subsequent subclinical lymph node metastases. However, the sensitivity of sonography in the detection of smaller metastatic nodes was lower than that of computed tomography.

Iridium-192 implantation for T1 and T2a carcinoma of the tongue and floor of mouth: retrospective study of the results of treatment at the Royal Berkshire Hospital

Carcinomas of the tongue and floor of mouth are relatively rare tumours, which may be treated using several modalities. We reviewed the results of iridium wire implants performed at the Royal Berkshire Hospital between 1994 and 2000. 24 patients had iridium wire implants as primary treatment for tongue and floor of mouth cancers. Four patients were treated after excision biopsy with close or involved margins. One patient was treated for a recurrence after surgery. The median age at treatment was 61 years. There were 18 men and 11 women. 21 patients had tumours of the tongue and eight of the floor of mouth. 13 had T1 tumours and 11 had T2a tumours. The median follow up was 42 months. The primary tumour was controlled in 22 of the 29 patients by the implant alone. Of the seven patients with local recurrence four were successfully salvaged with surgery. The acturarial 2 year survival rates were: overall survival 81%, disease specific survival 91%, local recurrence free survival 85% and nodal relapse free survival 76%. The recorded complication rate was low, one patient developing radionecrosis of the mandible at 7 years post implant. We believe these results show that brachytherapy remains a treatment option for patients with early tongue carcinoma with a high rate of local control and low toxicity.

Etoposide-mediated sensitization of squamous cell carcinoma cells to tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-induced loss in mitochondrial membrane potential

Squamous cell carcinoma (SCC) cell lines (MIT7-x(L), MIT8, and MIT16) that overexpress Bcl-x(L) have been demonstrated to show resistance to multiple chemotherapeutic drugs. Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL), which belongs to the TNF family of proteins, induces apoptosis in tumor, but not in normal, cells. In the present study, we examined whether etoposide sensitizes tumor cells with multiple-drug-resistance to TRAIL-induced apoptosis. Sequential treatment with etoposide and TRAIL resulted in a synergistically induced cell death in the two resistant lines (MIT7-x(L) and MIT16) but not MIT8, as assessed by WST-8 assay. As expected, MIT7 cells (a drug-sensitive line) were sensitive to the combined treatment. The cell death caused by both etoposide and TRAIL appears to involve apoptosis, since the combined treatment caused a loss in mitochondrial membrane potential (DeltaPsim), which is closely associated with apoptosis induction. The density of the TRAIL-receptors (TRAIL-Rs) was not appreciably modulated by the etoposide treatment, suggesting that etoposide targets molecule(s) downstream of the TRAIL-Rs. Regardless of the molecular mechanisms underlying the cell death, sequential treatment with etoposide and TRAIL could be useful in the design of treatment modalities for patients with SCC, especially those with elevated levels of Bcl-x(L).

Recurrent neck disease in oral cancer

PURPOSE

The goals were to examine the clinical and pathologic features of patients who developed metastatic squamous cell carcinoma in the cervical lymph nodes after initial treatment and to identify any common patterns.

PATIENTS AND METHODS

A retrospective analysis of 35 patients of varying initial tumor stage was performed. There were 18 patients who had an initial neck dissection and 17 patients whose neck was managed by a "watch and wait" policy.

RESULTS

Recurrence frequently involved level II nodes, and extracapsular spread was invariably present. The time taken for recurrence to develop was the same in both groups of patients (15 months, P =.35), and the overall median survival time after recurrence was 18 months (12 to 25 months, 95% confidence interval). In 27 of 29 patients (93%) who had the primary tumor resected, the thickness of tumor was greater than 5 mm.

CONCLUSION

Neck recurrence may represent residual disease; it has histologically unfavorable features and consequently a poor prognosis. The frequency of recurrence at level II emphasizes the need for meticulous dissection in this region, and tumor thickness needs to be considered in planning treatment of the clinically negative neck.