Progression of gingival squamous cell carcinoma from early to late stage after invasive dental procedure

Early presentation of gingival squamous cell carcinoma (GSCC) is at times misdiagnosed as a benign inflammatory or reactive oral condition. Some misdiagnosed patients undergo unnecessary, invasive dental procedures, resulting in delayed cancer diagnosis and an increased risk of accelerated disease progression due to disruption of the periosteum and cortical bone. The records of 58 patients with biopsy-proven GSCC were retrospectively reviewed. The sample included 32 patients who underwent an invasive dental procedure (IDP) prior to cancer diagnosis and 26 patients who did not undergo an IDP (non-case group). Patients from both groups initially presented with similar symptoms. The median duration of symptoms at initial clinical presentation was 6 months for the IDP group and 2 months for the non-case group. In IDP patients, symptoms worsened after the IDP was rendered, with 37.5% presenting with a severe-grade symptom. In both groups, the majority of lesions were found on the posterior mandible and had a histologic grading of moderately differentiated GSCC. The odds of the IDP group having late-stage disease were 2.94 times greater than the odds for the control group. Stage T3/T4 malignancy was diagnosed in 77.4% of the IDP patients versus 53.8% of non-case patients. Disease-specific mortality was comparable; however, surgical treatment was significantly more extensive in the IDP group than in the non-case group. The disruption of alveolar periosteum in undiagnosed oral cancer patients results in significant delay in diagnosis, necessitating more complicated treatment regimens because of local tumor progression.

Intraoperative optical assessment of photodynamic therapy response of superficial oral squamous cell carcinoma

This study investigated whether diffuse optical spectroscopy (DOS) measurements could assess clinical response to photodynamic therapy (PDT) in patients with head and neck squamous cell carcinoma (HNSCC). In addition, the correlation between parameters measured with DOS and the crosslinking of signal transducer and activator of transcription 3 (STAT3), a molecular marker for PDT-induced photoreaction, was investigated. Thirteen patients with early stage HNSCC received the photosensitizer 2-[1-hexyloxyethyl]-2-devinylpyropheophorbide-a (HPPH) and DOS measurements were performed before and after PDT in the operating room (OR). In addition, biopsies were acquired after PDT to assess the STAT3 crosslinking. Parameters measured with DOS, including blood volume fraction, blood oxygen saturation (StO2), HPPH concentration (cHPPH), HPPH fluorescence, and blood flow index (BFI), were compared to the pathologic response and the STAT3 crosslinking. The best individual predictor of pathological response was a change in cHPPH (sensitivity=60%, specificity=100%), while discrimination analysis using a two-parameter classifier (change in cHPPH and change in StO2) classified pathological response with 100% sensitivity and 100% specificity. BFI showed the best correlation with the crosslinking of STAT3. These results indicate that DOS-derived parameters can assess the clinical response in the OR, allowing for earlier reintervention if needed.

Sentinel node biopsy in lieu of neck dissection for staging oral cancer

IMPORTANCE

Neck dissection is the standard staging procedure to ascertain the pathologic status of cervical lymph nodes in patients with oral cavity squamous cell carcinoma (OSCC), but it results in multiple morbidities.

OBJECTIVE

To examine outcomes of patients with OSCC who underwent sentinel node biopsy (SNB) as the sole neck staging procedure.

DESIGN

Retrospective review of patients who underwent SNB during the period 2005 through 2011.

SETTING

National Cancer Institute–designated comprehensive cancer center.

PARTICIPANTS

Thirty-eight patients with clinically T1 or T2N0 OSCC.

INTERVENTIONS

Preoperative lymphoscintigraphy with intraoperative gamma probe localization was used. Sentinel lymph nodes were serially sectioned, formalin fixed, and examined at 3 levels. All patients with positive SNB results underwent neck dissection, and the patients with negative SNB results were observed clinically.

MAIN OUTCOMES AND MEASURES

Sensitivity and predictive value of SNB, recurrence rates, and disease-specific survival rates.

RESULTS

There were 18 T1 and 20 T2 tumors. Five patients had positive SNB results, of whom 3 had additional positive nodes on subsequent neck dissection. Two of 33 patients with negative SNB results developed a regional recurrence. The sensitivity and negative predictive value for staging the neck with SNB alone were 71% (5 of 7) and 94% (31 of 33), respectively. Mean follow-up was 31 months. The mean disease-free survival duration for patients with positive and negative SNB results was 30 and 65 months, respectively (P = .08). The disease-specific survival rate for patients with positive and negative SNB results was 80% and 91%, respectively. There was no significant difference in disease-specific survival between patients with true-negative and false-negative SNB results (34 vs 44 months; P = .38).

CONCLUSIONS AND RELEVANCE

The majority of patients with positive results on SNB had additional positive nodes on neck dissection. A low rate of isolated neck recurrence was found in patients with negative results on SNB. Individuals with negative results on SNB exhibited better overall and disease-specific survival than those with positive results.

Photodynamic therapy with 3-(1'-hexyloxyethyl) pyropheophorbide a for cancer of the oral cavity

PURPOSE

The primary objective was to evaluate safety of 3-(1'-hexyloxyethyl)pyropheophorbide-a (HPPH) photodynamic therapy (HPPH-PDT) for dysplasia and early squamous cell carcinoma of the head and neck (HNSCC). Secondary objectives were the assessment of treatment response and reporters for an effective PDT reaction.

EXPERIMENTAL DESIGN

Patients with histologically proven oral dysplasia, carcinoma in situ, or early-stage HNSCC were enrolled in two sequentially conducted dose escalation studies with an expanded cohort at the highest dose level. These studies used an HPPH dose of 4 mg/m(2) and light doses from 50 to 140 J/cm(2). Pathologic tumor responses were assessed at 3 months. Clinical follow up range was 5 to 40 months. PDT induced cross-linking of STAT3 were assessed as potential indicators of PDT effective reaction.

RESULTS

Forty patients received HPPH-PDT. Common adverse events were pain and treatment site edema. Biopsy proven complete response rates were 46% for dysplasia and carcinoma in situ and 82% for squamous cell carcinomas (SCC) lesions at 140 J/cm(2). The responses in the carcinoma in situ/dysplasia cohort are not durable. The PDT-induced STAT3 cross-links is significantly higher (P = 0.0033) in SCC than in carcinoma in situ/dysplasia for all light doses.

CONCLUSION

HPPH-PDT is safe for the treatment of carcinoma in situ/dysplasia and early-stage cancer of the oral cavity. Early-stage oral HNSCC seems to respond better to HPPH-PDT in comparison with premalignant lesions. The degree of STAT3 cross-linking is a significant reporter to evaluate HPPH-PDT-mediated photoreaction.

Interlesion differences in the local photodynamic therapy response of oral cavity lesions assessed by diffuse optical spectroscopies

Photodynamic therapy (PDT) efficacy depends on the local dose deposited in the lesion as well as oxygen availability in the lesion. We report significant interlesion differences between two patients with oral lesions treated with the same drug dose and similar light dose of 2-1[hexyloxyethyl]-2-devinylpyropheophorbide-a (HPPH)-mediated photodynamic therapy (PDT). Pre-PDT and PDT-induced changes in hemodynamic parameters and HPPH photosensitizer content, quantified by diffuse optical methods, demonstrated substantial differences between the two lesions. The differences in PDT action determined by the oxidative cross-linking of signal transducer and activator of transcription 3 (STAT3), a molecular measure of accumulated local PDT photoreaction, also showed >100-fold difference between the lesions, greatly exceeding what would be expected from the slight difference in light dose. Our results suggest diffuse optical spectroscopies can provide in vivo metrics that are indicative of local PDT dose in oral lesions.

Abstract A15: Autofluorescence-guided detection of oropharyngeal neoplasms and precursor lesions

Introduction: The incidence of oropharyngeal (OP) cancer has been increasing, in contrast to the overall head and neck tumors, likely related to human papillomavirus infection (HPV). Early clinical detection of oral cavity (OC) and OP tumors and precursors is essential for early intervention and chemoprevention. Since the oropharynx is less accessible than the OC, altering the current screening practice may be necessary. The addition of autofluorescence visualization (AFV) to standard examination has proven valuable by accurately detecting low and high-grade preneoploastic lesions (LGLs, HGLs) and oral cancers but its value in the OP has not been studied to date. We aim to assess if adding AFV to routine white light exam (WLE) increases the detection of OP neoplasms and precursor lesions.

Study Design: High-risk patients with suspicious OC or OP lesions or recently diagnosed, untreated carcinoma underwent examination with WLE followed by AFV at 405nm from a 10mm rigid endoscope. Biopsies were obtained from areas with positive suspicion on either WLE or AFV examinations. Lesions were stratified on central pathology review as benign, low-grade (parakeratosis with atypia (PKA) or mild dysplasia), high-grade (moderate dysplasia, severe dysplasia, or carcinoma in situ (CIS)), or cancer. Sensitivity and specificity were calculated for WLE, AFV, and WLE + AFV for all patients with an OP biopsy on the first visit.

Results: A series of 143 patients under active surveillance at our institute were examined over 218 visits and a total of 664 biopsies were collected. Twenty-nine patients (20%) had 41 biopsies (6%) sampled from the OP or OC/OP junction as follows: 5 base of tongue (BOT), 17 soft palate (SP), 10 tonsil, 5 SP/tonsillar junction, 3 hard palate/SP junction, and 1 BOT/posterior lateral tongue junction. Of the 29 LGLs/HGLs on the tonsil/SP/BOT, 14/29 were missed on WLE and 3/29 were missed on AFV. Out of 13 LGLs/HGLs on the SP, 5/13 were missed on WLE and 2/13 were missed on AFV. One severe dysplasia and one CIS were missed on WLE of the SP but none were missed with AFV. Of the 11 LGLs/HGLs on the tonsil or SP/tonsillar junction, 5/11 were missed on WLE and none were missed on AFV. One moderate dysplasia was missed on WLE of the tonsils but none were missed on AFV. Out of 5 LGLs/HGLs on the BOT, 4/5 were missed on WLE and 1/5 was missed on AFV. For the BOT, 4 mild dysplasias were missed on WLE and one was missed on AFV. Overall, WLE alone vs. AFV alone vs. AFV+ WLE detected 35% vs. 85% vs. 95% of LGLs respectively. Of the LGLs, 7 were PKA and 13 were mild dysplasia. WLE alone vs. AFV alone vs. the addition of AFV+ WLE detected 75% vs. 100% vs. 100% of HGLs respectively. Of the HGLs, one was moderate dysplasia, 5 severe dysplasias and 6 were CIS. All 3 modalities 100% detected the 2 cancers. Seven biopsies were benign. The addition of AFV+WLE greatly improved sensitivity in detecting LGLs when compared with WLE alone (95% vs. 35%) and HGLs (100% vs. 75%). The specificity in detecting both LGLs and HGLs decreased from 85.7% with WLE to 42.9% with AFV+WLE.

Conclusions: AFV has high sensitivity in detecting OP lesions that may have been missed by WLE. Multi-modality visualization has utility in detecting pre-malignant lesions that may serve as potential targets for chemoprevention or early intervention. The addition of AFV to WLE may be useful in screening patients for chemoprevention trials. Due to its low specificity, AFV may be best limited to screening high-risk populations.

Citation Information: Cancer Prev Res 2011;4(10 Suppl):A15.

In vitro cellular uptake and dimerization of signal transducer and activator of transcription-3 (STAT3) identify the photosensitizing and imaging-potential of isomeric photosensitizers derived from chlorophyll-a and bacteriochlorophyll-a

Among the photosensitizers investigated, both ring-D and ring-B reduced chlorins containing the m-iodobenzyloxyethyl group at position-3 and a carboxylic acid functionality at position-17(2) showed the highest uptake by tumor cells and light-dependent photoreaction that correlated with maximal tumor-imaging [positron emission tomography (PET) and fluorescence] and long-term photodynamic therapy (PDT) efficacy in BALB/c mice bearing Colon26 tumors. However, among the ring-D reduced compounds, the isomer containing the 1'-m-iobenzyloxyethyl group at position-3 was more effective than the corresponding 8-(1'-m-iodobenzyloxyethyl) derivative. All photosensitizers showed maximum uptake by tumor tissue 24 h after injection, and the tumors exposed with light at low fluence and fluence rates (128 J/cm(2), 14 mW/cm(2)) produced significantly enhanced tumor eradication than those exposed at higher fluence and fluence rate (135 J/cm(2), 75 mW/cm(2)). Interestingly, dose-dependent cellular uptake of the compounds and light-dependent STAT3 dimerization have emerged as sensitive rapid indicators for PDT efficacy in vitro and in vivo and could be used as in vitro/in vivo biomarkers for evaluating and optimizing the in vivo treatment parameters of the existing and new PDT candidates.

Monitoring photobleaching and hemodynamic responses to HPPH-mediated photodynamic therapy of head and neck cancer: a case report

We present initial results obtained during the course of a Phase I clinical trial of 2-1[hexyloxyethyl]-2-devinylpyropheophorbide-a (HPPH)-mediated photo-dynamic therapy (PDT) in a head and neck cancer patient. We quantified blood flow, oxygenation and HPPH drug photobleaching before and after therapeutic light treatment by utilizing fast, non-invasive diffuse optical methods. Our results showed that HPPH-PDT induced significant drug photobleaching, and reduction in blood flow and oxygenation suggesting significant vascular and cellular reaction. These changes were accompanied by cross-linking of the signal transducer and activator of transcription 3 (STAT3), a molecular measure for the oxidative photoreaction. These preliminary results suggest diffuse optical spectroscopies permit non-invasive monitoring of PDT in clinical settings of head and neck cancer patients.

Abstract B56: Autofluorescence visualization to screen for premalignant and malignant lesions of oral cavity and oropharynx

B56

Objective

To determine if the addition of autofluorescence (AF) visualization to conventional white light exam (WL) improves the efficiency in detecting pre-malignant and malignant lesions in the oral cavity of high risk patients, compared to WL exam alone.

Methods

A total of 47 patients underwent the screening procedure at the department of Dentistry and Head and Neck Surgery at Roswell Park Cancer Institute, between October 2006 and June 2007, either to investigate suspicious oral lesions or to identify any co-existing lesions in patients with a recently diagnosed untreated oral pre-malignant lesions or cancer of oral cavity. Four patients had a second exam at least 6 months after the initial visit, making up a total of 51 screening visits. The patients underwent a comprehensive oral exam with an autofluorescence device which was equipped with WL source, an AF source (blue excitation light at 405 nm and imaging at 530-550 & 630-650 nm) and a video camera. Any area that looked fluorescent green was classified as normal and any area that showed loss of fluorescence (grey or black) was considered to be suspicious on AF. All oral exams were performed by one dentist and the biopsies were reviewed by the same pathologist. A total of 170 lesions were identified on either WL or AF and biopsied, and 1 contra-lateral control biopsy from a normal looking area was taken per visit. For convenience of analysis, the pathologic diagnoses were grouped into four categories: (1) ‘benign lesions’(BL) - normal/ unremarkable samples with benign conditions and parakeratosis without atypia (2) ‘low grade lesions’(LGL) - parakeratosis with atypia and mild dysplasia (3) ‘high grade lesions’(HGL) - moderate dysplasia (MD), severe dysplasia (SD) and CIS (4) ‘Carcinoma’(CA). These groups contributed 48, 129, 26 and 15 biopsies respectively.

Results

On lesion-by-lesion basis, while WL exam did not identify 8 HGLs (4 MD and 4 CIS), AF missed only one HGL (1 MD). Similarly, WL exam did not identify 4 CAs, whereas AF exam missed only 1 cancerous lesion. On combined sequential screening by WL followed by AF (WL+AF), none of the HGLs or CAs was missed. For the LGLs, the sensitivity improved from 44% with WL to 63% with AF and 76% with WL+AF exam. Similarly, sensitivity for detecting HGLs increased from 69% with WL to 96 and 100% with AF and WL+AF, respectively. For CAs, the sensitivity improved from 73% to 93 and 100% with AF and WL+AF respectively. The negative predictive value of WL for HGLs and CAs was 96 and 97% respectively, which increased to 100% with AF alone. The specificity for HGLs and CAs was superior with WL at 75% compared to 52% with AF alone. The addition of AF to WL increased the relative sensitivity by 83%, 47% and 45% in identifying LGLs, HGLs and CAs respectively. One per-person basis, we examined the efficiency of AF in identifying the highest grade lesion in a person. While, WL missed the highest grade lesions in 2 patients with MD, 2 with CIS and 4 with CAs; AF did not miss the worst lesion in any patient with a HGL or CA. The efficacy of AF in identifying the highest grade lesion in each individual was 100%.

Conclusion

Our results demonstrate that sequential exam by AFL visualization following a WL exam is very efficient in identifying pre-malignant and malignant oral lesions not detected with WL alone. This technique has the potential as a non-invasive and effective tool for oral cancer screening.

Citation Information: Cancer Prev Res 2008;1(7 Suppl):B56.

Challenges in array comparative genomic hybridization for the analysis of cancer samples

PURPOSE

To address some of the challenges facing the incorporation of array comparative genomic hybridization technology as a clinical tool, including archived tumor tissue, tumor heterogeneity, DNA quality and quantity, and array comparative genomic hybridization platform selection and performance.

METHODS

Experiments were designed to assess the impact of DNA source (e.g., archival material), quantity, and amplification on array comparative genomic hybridization results. Two microdissection methods were used to isolate tumor cells to minimize heterogeneity. These data and other data sets were used in a further performance comparison of two commonly used array comparative genomic hybridization platforms: bacterial artificial chromosome (Roswell Park Cancer Institute) and oligonucleotide (Agilent Technologies, Santa Clara, CA).

RESULTS

Array comparative genomic hybridization data from as few as 100 formalin-fixed, paraffin-embedded cells isolated by laser capture microdissection and amplified were remarkably similar to array comparative genomic hybridization copy number alterations detected in the bulk (unamplified) population. Manual microdissection from frozen sections provided a rapid and inexpensive means to isolate tumor from adjacent DNA for amplification and array comparative genomic hybridization. Whole genome amplification introduced no appreciable allele bias on array comparative genomic hybridization. The array comparative genomic hybridization results provided by the bacterial artificial chromosome and Agilent platforms were concordant in general, but bacterial artificial chromosome array comparative genomic hybridization showed far fewer outliers and overall less technical noise, which could adversely affect the statistical interpretation of the data.

CONCLUSIONS

This study demonstrates that copy number alterations can be robustly and reproducibly detected by array comparative genomic hybridization in DNA isolated from challenging tumor types and sources, including archival materials, low DNA yield, and heterogeneous tissues. Furthermore, bacterial artificial chromosome array comparative genomic hybridization offers the advantage over the Agilent oligonucleotide platform of presenting fewer outliers, which could affect data interpretation.

Synovial sarcoma of the larynx in a 79-year-old woman, confirmed by karyotyping and fluorescence in situ hybridization analysis

BACKGROUND

Synovial sarcoma is an uncommon tumor of the head and neck and is an exceedingly rare finding in the larynx. Generally, it afflicts younger patients and most often occurs in the hypopharynx.

METHODS AND RESULTS

We report a case of a biphasic synovial sarcoma arising in the arytenoid fold of a 79-year-old woman. The diagnosis was confirmed by an extensive immunohistochemical panel, karyotyping, and fluorescence in situ hybridization (FISH). The patient was treated with total laryngectomy, and she did well postoperatively.

CONCLUSION

To our knowledge, our patient is the oldest ever to be reported in the literature, concluding that although this entity is considered a disease of young patients, it still has to be included in the differential diagnosis in older patients. Second, our report is only the third to describe t(X;18) (p11.2;q11.2) by karyotyping and the first ever by using FISH analysis, thus adding more cytogenetic data to the literature in this rare location and confirming the use of FISH in making the accurate diagnosis.

The introducer technique is the optimal method for placing percutaneous endoscopic gastrostomy tubes in head and neck cancer patients

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tubes are often placed in head and neck cancer patients to provide nutritional support, but studies have found the complication rates to be higher than other subsets of patients who undergo PEG placement. Complication rates as high as 50% have been reported, with the bulk of these complications being PEG site issues (i.e., cellulitis, abscess, fascitis, and tumor implantation). Because the pull technique has been the primary technique used, the theory is that the transoral tube passage is the source of the complications in these patients. Alternatively, the introducer technique uses a transabdominal approach to place the device, avoiding any tube contamination by upper aerodigestive organisms or tumor cells. At our institution, this technique has been used exclusively for head and neck cancer patients and this article reports our experience.

METHODS

One hundred forty-nine head and neck cancer patients who had a prophylactic PEG tube placed were reviewed from January 1, 1999 to December 31, 2003. The rates of placement success, morbidity, and complications were determined.

RESULTS

Successful placement was achieved in 148 (99%) patients without any PEG-related deaths. Overall, 17 complications (11%) occurred, with only one major complication (0.7%) identified. PEG site infections were uncommon with only five cases (3.4%) and all were mild cellulitis.

CONCLUSIONS

The introducer technique is the safest method for PEG tube placement in head and neck cancer patients. The overall rate of complications is low and PEG site infectious complications are rare. The introducer technique should be the method of choice for PEG tubes in head and neck cancer patients.

Malignant hypercalcemia associated with a parathyroid macrocyst and the early genesis of a giant cell tumor

Parathyroid cysts rarely cause primary hyperparathyroidism. In most cases, the resultant hypercalcemia is mild and detected before any significant skeletal disease develops. We report a patient with severe hypercalcemia, a synchronous brown tumor (osteitis fibrosa cystica) of the maxilla, and a large benign functional parathyroid cyst. The unusual patient presentation and management are described and illustrated. The pertinent literature is reviewed.

Sentinel Lymph Node Biopsy: A Rational Approach for Staging T2N0 Oral Cancer

OBJECTIVES/HYPOTHESIS

For oral cancer patients, the presence of neck nodal metastases is the most important disease prognosticator. However, a significant proportion of clinically N0 patients harbor occult microscopic nodal metastasis. Our objective was to determine the feasibility and accuracy of sentinel node biopsy (SNB) in the staging of T2N0 oral carcinoma patients.

STUDY DESIGN

Prospective analysis.

METHODS

Twenty patients with previously untreated N0 oral cavity squamous cell carcinoma were studied. Each patient had an SNB performed using preoperative technetium sulfur colloid lymphoscintigraphy, intraoperative gamma probe guidance, and intraoperative peritumoral injection of 1% isosulfan blue. All patients underwent neck dissection. The sentinel lymph nodes (SLNs) were sectioned in 2- to 3-mm intervals, formalin fixed, and sectioned at three levels. The non-SLNs were sectioned in a routine manner for histologic examination.

RESULTS

SLNs were identified in all patients (100%) and accurately predicted the pathologic nodal status in 18 of 20 patients (90%). Tumor was found exclusively in the SLNs in six patients (30%). Two patients had positive SLNs at multiple neck levels. Two patients had a negative SLN and a positive non-SLN (false-negative findings). Occult nodal metastases were present in 60% of the cohort.

CONCLUSIONS

SNB is a technically feasible and accurate procedure for staging the neck in oral carcinoma patients. However, SNB accuracy is lower for floor of the mouth lesions. The rate of occult nodal metastases identified in this cohort is higher than previously reported in the literature. These results suggest that SNB warrants further multi-institutional studies.

Genomic Instability, DNA Alterations and Tumor Eosinophilic Expression in Head and Neck Squamous Cell Carcinoma

The progression of normal cells to invasive tumor cells has been attributed to the acquisition of numerous mutations in the genome; genomic instability (GI) facilitates the accumulation of these mutations. To study the GI in head and neck squamous cell carcinoma (HNSCC), the genomic instability index (GII) was examined; chromosomal gains and losses were evaluated by array comparative genomic hybridization (aCGH), which were confirmed by fluorescence in situ hybridization (FISH). Histopathological eosinophilic infiltrate (Eos Infil), as an adjunct measure of tumor invasiveness, was also considered and compared to GI.

MATERIALS AND METHODS

Inter-simple sequence repeat PCR (ISSR-PCR) was utilized to determine the GII (a quantitative estimate of the relative overall genomic damage). GII was measured in 26 pairs of tumor and normal HNSCC samples. Array CGH was conducted using bacterial artificial chromosome (BAC) clones to evaluate amplifications and deletions (n=20 tumor), and confirmation of the specific changes was made by FISH analysis. Histopathological evaluation of Eos Infil for all samples was performed to calculate the eosinophilic index (EI). This was accomplished by observing Eos Infil in neoplastic tissue and at the tumor/normal tissue interface.

RESULTS

GI was evident in 25 of the 26 tumors. The GIIs ranged from 0 to 5.3% with a mean of 2.8% (similar to the results reported for colorectal and thyroid carcinomas). GIIs were higher in tumors of the oral cavity (OC) than in tumors from other subsites of HNSCC (p=0.05). Chromosomal alterations were identified by array CGH on chromosomes 8, 11 and 17, but consistent amplifications were observed on (8q21.3-23.5) in 80% of the tumors. These changes were confirmed using FISH analysis. There was an association between increased GI and rising EI, but this did not achieve statistical significance (p>0.05).

CONCLUSION

HNSCC exhibits a similar degree of GI to that previously reported in colorectal and thyroid malignancies. The higher GI identified in OC tumors could be explained by a greater degree of the damage from environmental carcinogens (smoke, diet and alcohol) to the first station of the areodigestive tract. Consistent amplification at the specific loci of 8q might be attributed to mutations in various genes, such as SHAX3 (Snf7 homolog, associated with Alix 3, involved in apoptosis and endocytosis) and E2F5 (transcription factor 5 that interacts with tumor suppressor proteins). EI was not associated with age, sex, site or stage of tumor in established cases. Further work up will be necessary to explain these results.

Primary adenocarcinoma of cervical esophagus

Most upper esophageal malignancies are squamous cell carcinomas, rarely adenocarcinomas arising from Barrett's esophagus and very rarely adenocarcinomas from heterotopic gastric mucosa without evidence of Barrett's especially in the cervical part of the esophagus. We report a case of adenocarcinoma of the polypoid type in the upper esophagus (cervical esophagus) arising from ectopic gastric mucosa, in a 60 year-old man who presented with progressive dysphagia. Accurate diagnosis by esophagogram revealed a large mass in the cervical esophagus; CAT scan showed intraluminal mass at the level of thoracic inlet, esophagogastroscopy showed a fleshy polyp (3.2cm x 3.0cm) at 20 cm from the incisors with a biopsy confirming moderately differentiated adenocarcinoma with no evidence of Barrett's esophagus. Through a left cervical approach and resection of medial third of clavicle, the tumor was removed by partial esophagectomy followed by lymph node dissection, and proved to be T1NOMO, stage I (AJCC staging 6th ed.). Post operatively, the patient received chemoradiation with no evidence of recurrence or metastasis in six years of follow up. It seems this tumor has a much better prognosis than adenocarcinomas arising from Barrett's. To our knowledge only 19 cases have been reported in literature so far.

Tissue eosinophilia: a morphologic marker for assessing stromal invasion in laryngeal squamous neoplasms

Background

The assessment of tumor invasion of underlying benign stroma in neoplastic squamous proliferation of the larynx may pose a diagnostic challenge, particularly in small biopsy specimens that are frequently tangentially sectioned. We studied whether thresholds of an eosinophilic response to laryngeal squamous neoplasms provides an adjunctive histologic criterion for determining the presence of invasion.

Methods

Eighty-seven(n = 87) cases of invasive squamous cell carcinoma and preinvasive squamous neoplasia were evaluated. In each case, the number of eosinophils per high power field(eosinophils/hpf), and per 10 hpf in the tissue adjacent to the neoplastic epithelium, were counted and tabulated. For statistical purposes, the elevated eosinophils were defined and categorized as: focally and moderately elevated (5–9 eos/hpf), focally and markedly increased(>10/hpf), diffusely and moderately elevated(5–19 eos/10hpf), and diffusely and markedly increased (>20/10hpf).

Results

In the invasive carcinoma, eosinophil counts were elevated focally and /or diffusely, more frequently seen than in non-invasive neoplastic lesions. The increased eosinophil counts, specifically >10hpf, and >20/10hpf, were all statistically significantly associated with stromal invasion. Greater than 10 eosinophils/hpf and/or >20 eosinophils/10hpf had highest predictive power, with a sensitivity, specificity and positive predictive value of 82%, 93%, 96% and 80%, 100% and 100%, respectively. Virtually, greater than 20 eosinophils/10 hpf was diagnostic for tumor invasion in our series.

Conclusion

Our study suggests for the first time that the elevated eosinophil count in squamous neoplasia of the larynx is a morphologic feature associated with tumor invasion. When the number of infiltrating eosinophils exceeds 10/hpf and or >20/10 hpf in a laryngeal biopsy with squamous neoplasia, it represents an indicator for the possibility of tumor invasion. Similarly, the presence of eosinophils meeting these thresholds in an excisional specimen should prompt a thorough evaluation for invasiveness, when evidence of invasion is absent, or when invasion is suspected by conventional criteria in the initial sections.

Lipomatous hemangiopericytoma of the head and neck: immunohistochemical and DNA ploidy analyses

BACKGROUND

Lipomatous hemangiopericytoma (LHPC) is a newly described rare soft tissue tumor with unpredictable biologic behavior and is difficult to diagnose by conventional histologic parameters. The molecular analyses of this entity to date are sparse. Only a few cases of LHPC have been reported. Although one case of LHPC in the sinonasal region was briefly reported, this is the first case in the head and neck region with detailed clinicopathologic features and molecular analysis of this entity.

METHODS

We reported a case of LHPC in a 55-year-old woman with a slowly growing lesion in the occipital area that was diagnosed by CT and MRI and removed surgically. Immunohistochemical and DNA ploidy analyses were performed.

RESULTS

A panel of 16 markers was included for immunohistochemical analysis. Diffuse immunopositivity of CD57 in our case provides supportive evidence that LHPC is linked with HPC because this marker is also present in approximately 50% of conventional HPCs. CD57 should be used in the immunohistochemical panel in any lesion suspected to be LHPC. Furthermore, CD57 along with CD34 and XIIIa is thought to stain for primitive mesenchymal stem cells, suggesting a bimodal/multimodal differentiation of LHPC. By flow cytometry, we found that tumor cells were 100% diploid with the S-phase fraction (SPF) being 3.21%. A significant positive correlation was detected between nuclear proliferating index and SPF (p < 0.001, by Spearman analysis). These findings provide molecular evidence indicating a benign nature of LHPC.

CONCLUSIONS

Contrary to the old belief that HPC has an aggressive nature, this variant of tumor looks less aggressive. The patient was followed for 1 year without any evidence of recurrence, supporting our pathologic hypothesis.

Definition of a region of loss of heterozygosity at chromosome 11q23.3-25 in head and neck squamous cell carcinoma using laser capture microdissection technique

To date, loss of heterozygosity (LOH) studies on HNSCC have had limited success in identifying a confined region of loss on chromosome 11q partially due to the heterogeneous nature of tumor tissue examined. Additionally, little is known about the role of the 11q allelic deletion in HNSCC tumorigenesis and current reports are conflicting. The aim of this study was to better define LOH at distal 11q by using combination of a pure cell population procured by laser capture microdissection (LCM) and subsequent sensitive PCR amplification of polymorphic microsatellites. This study analyzed HNSCC for LOH using a panel of 5 microsatellite markers spanning 11q23-25. Thirty-four paired DNA samples from tumor and autologous normal tissue were harvested by LCM technique to ensure a pure cell population for PCR amplification. Approximately 2000 to 3000 cells were procured from each sample. Twenty-one of 34 cases (62%, P < 0.001) showed LOH on at least one of the loci examined. The highest frequency of LOH was found at the 11q23.3-25 segment, with 44% at marker D11S968 and 35% at marker D11S1316. A distinct novel region of frequent LOH at 11q23.3-25, defined by D11S1316 and D11S968, was identified. No allelic loss was found in any normal squamous tissue samples. To study LOH in HNSCC, combination of pure cell population procurement by LCM and sensitive PCR provides a more accurate approach than the conventional method using a bulk of heterogeneous tissue. A novel region of LOH at 11q23.3-25 was defined. LOH in this region may harbor putative tumor suppressor gene(s) critical for HNSCC. Furthermore, these allelic losses were not found in any non-neoplastic squamous tissue samples, clarifying prior discrepant data.

Fibrin glue-reinforced closure of postlaryngectomy pharyngocutaneous fistula

Pharyngocutaneous fistulization is a dreaded and devastating complication of laryngectomy. Although the specific risk factors are controversial, a history of prior radiation therapy has generally been accepted to be a major risk factor for developing this complication. We present a case of a postlaryngectomy pharyngocutaneous fistula developing in a previously irradiated patient that was successfully managed by incorporating fibrin glue into the surgical closure. We also discuss the underlying theoretical basis for this approach by reviewing the relevant literature.

Cancer of the buccal mucosa: are margins and T-stage accurate predictors of local control?

Cancer of the buccal mucosa is an uncommon and aggressive neoplasm of the oral cavity. Less than 2% of patients treated for cancer of the oral cavity at Roswell Park Cancer Institute (RPCI) from 1971 to 1997 had primary buccal cancers. Because the majority of these patients did not undergo any adjuvant treatment, this group provided us with the opportunity to assess the relationship between margin status and local recurrence for both small (T1-T2) and large (T3-T4) tumors treated with surgery alone.

MATERIALS AND METHODS

The RPCI tumor registry database reported 104 patients who were treated for buccal carcinoma. A retrospective chart review identified 27 patients who met our criteria for a buccal mucosal primary tumor (epicenter of the mass in the buccal mucosa). There were 13 men and 14 women, ranging in age from 34 to 94 years (mean, 75). Data were collected regarding patient demographics, presenting symptoms, stage, treatment received, and outcome.

RESULTS

All patients underwent surgical resection of their primary lesion; 21 (75%) had T1 or T2 tumors. The rate of local recurrence was 56% for the group as a whole. Patients with close or positive margins had a 66% local failure rate as compared with 52% when surgical margins were negative (greater than or equal to 5 mm from the resection margin after tissue fixation; P = ns). Among those in whom negative margins were achieved, patients with T1-T2 disease had a 40% local failure rate with surgical resection alone.

CONCLUSIONS

Local excision of T1 and T2 buccal mucosa cancers with pathologically negative margins had a high rate of local recurrence in our series. Low T-stage and negative margins are not adequate predictors of local control. Even early buccal tumors may benefit from adjuvant therapy to enhance local control.