Recognition of oral potentially malignant disorders and transformation to oral cancer

Oral potentially malignant disorders refer to oral mucosal disorders with increased risk for malignant transformation, primarily to oral squamous cell carcinoma (SCC). Leukoplakia and erythroplakia are the most common of these disorders, but others have been identified. Transformation rates to oral cancer vary based on multiple factors. Healthcare providers should be aware of risk factors and clinical manifestations of these disorders and should intervene early to monitor and/or treat them to reduce the potential for malignant transformation.

Glottic Tuberculosis Masquerading as Early Multifocal Carcinoma

The incidence of tuberculosis has progressively decreased in developed countries after the advent of antituberculous chemotherapy, but has recently been increasing again mainly due to migratory flows. Although common in the past and considered to be a prelethal event, laryngeal involvement has become a rarity. We report the case of a 52-year-old female smoker who complained of persistent aphonia. Videostroboscopy showed bilateral vocal fold erythroleukoplakias. A chest X-ray and CT scan aroused the suspicion of lung tuberculosis, which was confirmed by Ziehl-Neelsen staining for acid-alcohol-fast bacilli on bronchoalveolar lavage. Antituberculous chemotherapy rapidly improved the quality of her voice and led to complete disappearance of the vocal fold lesions. In conclusion, laryngeal tuberculosis may mimic an early glottic multifocal carcinoma and should therefore, despite its rarity, always be considered in the differential diagnosis of erythroleukoplakia-like lesions in order to avoid improper surgical treatment and voice damage.

[THE ROLE OF PAPILLOMAVIRUS INFECTION IN THE DEVELOPMENT OF BACKGROUND DISEASE OF THE CERVIX]

Papillomavirus infection is one of the most common sexually transmitted infections. The aim of the study was to study the etiologic significance of the papillomavirus infection in the development of background diseases of the cervix and neoplasia. Under observation were 62 patients aged 18 to 55 years infected with human papillomavirus. All patients underwent complex clinical and anamnestic, laboratory and instrumental examination. Also, a review and advanced colposcopy was performed. As a result of the study, 53 (85.4%) women under observation were found to have various pathologies of the cervix. Dysplasia of mild degree (CIN 1 degree) was found in 12 (57.1%), moderate dysplasia (CIN 2 degree) - in 9 (42.9%) women. With further examination, it was found that patients along with dysplasia of varying severity had concomitant pathology of the cervix uteri. Cervical dysplasia was most often diagnosed in combination with another pathology of the cervix, which accounted for 85.7% of cases. It has been established that squamous epithelial lesion of the cervix is most often a consequence of late diagnosis and an untreated background process. At the same time, modern diagnostics requires a whole range of diagnostic measures to establish a diagnosis in the early stages of development and conduct differential diagnosis of a benign or malignant process.

Comprehensive SNP scan of DNA repair and DNA damage response genes reveal multiple susceptibility loci conferring risk to tobacco associated leukoplakia and oral cancer

Polymorphic variants of DNA repair and damage response genes play major role in carcinogenesis. These variants are suspected as predisposition factors to Oral Squamous Cell Carcinoma (OSCC). For identification of susceptible variants affecting OSCC development in Indian population, the "maximally informative" method of SNP selection from HapMap data to non-HapMap populations was applied. Three hundred twenty-five SNPs from 11 key genes involved in double strand break repair, mismatch repair and DNA damage response pathways were genotyped on a total of 373 OSCC, 253 leukoplakia and 535 unrelated control individuals. The significantly associated SNPs were validated in an additional cohort of 144 OSCC patients and 160 controls. The rs12515548 of MSH3 showed significant association with OSCC both in the discovery and validation phases (discovery P-value: 1.43E-05, replication P-value: 4.84E-03). Two SNPs (rs12360870 of MRE11A, P-value: 2.37E-07 and rs7003908 of PRKDC, P-value: 7.99E-05) were found to be significantly associated only with leukoplakia. Stratification of subjects based on amount of tobacco consumption identified SNPs that were associated with either high or low tobacco exposed group. The study reveals a synergism between associated SNPs and lifestyle factors in predisposition to OSCC and leukoplakia.

[Oral cavity changes in patients after kidney transplantation and preventive-treatment algorithms]

Kidney transplantation is the best option of treatment for patients with end-stage renal failure. However, following kidney transplantation many stomatological abnormalities are frequently reported. It is mainly due to immunosuppressive therapy and subsequent impaired immune response. There is an increased risk of infections and malignancies. The most frequent findings in the oral cavity include: aphthae, erosions of bacterial, viral and fungal origin, lichen-like or leukoplakia-like changes. The another type of change is gingival hyperplasia and its periodontologial consequences. In this review etiology, clinical symptoms of periodontological changes are described together with algorithm of pre- and posttransplant management of oral healthy is provided.

[Endoscopic chromoscopy in diagnosing and treatment of complicated gastroesophageal reflux disease]

The authors describe the results of examination and endoscopic treatment of 278 patients with clinical symptoms of gastroesophageal reflux disease. The method of fibroesophagoduodenoscopy with 3% Lugol aqueous solution chromoscopy was introduced in medical-diagnostic algorithm of the patients. Inclusion of chromoendoscopy in the program of examination and treatment of patients with gastroesophageal reflux disease allowed higher detection of severe epithelial dysplasia (to 10.3%), leukoplakia (to 62.1%) and esophagus cancer (to 3.5%) and improvement of the results of endoscopic treatment.

Natural history of potentially malignant oral lesions and conditions: an overview of the literature

At a workshop coordinated by the WHO Collaborating Centre for Oral Cancer and Pre-cancer in the UK issues related to potentially malignant disorders of the oral cavity were discussed by an expert group. The consensus views of the Working Group are presented in a series of papers. In this report we review the literature on the epidemiology and natural history of potentially malignant disorders (PMD), detailing those characteristics of the patients and lesions thought to be associated with future development of oral squamous cell carcinoma (OSCC). Older patients, particularly females are more at risk than younger patients; the duration of PMD may be important. Those who have never used tobacco seem at greater risk than smokers. OSCC is more likely with PMD on the lateral and ventral tongue, floor of mouth and retromolar/soft palate complex than with those elsewhere. The vast majority of PMD in which OSCC develop are non-homogenous although 5% of homogenous PMD will develop carcinoma. Large lesions covering several intraoral subsites also appear more at risk.

Tobacco smoke induces urokinase-type plasminogen activator and cell invasiveness: evidence for an epidermal growth factor receptor dependent mechanism

Multiple tobacco smoke-related premalignant and malignant lesions develop synchronously or metachronously in various organ sites, including the oral cavity. Both field cancerization and clonal migration seem to contribute to the occurrence of multiple tumors. Although the importance of endogenous factors (e.g., oncogenes) in regulating clonal migration is well established, little is known about the role of exogenous factors. Hence, the main objective of this study was to elucidate the mechanism by which tobacco smoke stimulated the migration of cells through extracellular matrix (ECM). Treatment of MSK-Leuk1 cells with a saline extract of tobacco smoke induced the migration of cells through ECM. Tobacco smoke induced the expression of urokinase-type plasminogen activator (uPA), resulting in plasmin-dependent degradation of ECM and increased cell migration. AG1478, a small-molecule inhibitor of the epidermal growth factor receptor (EGFR) tyrosine kinase, a neutralizing antibody to EGFR, or an antibody to amphiregulin, an EGFR ligand, also blocked tobacco smoke-mediated induction of uPA and cell migration through ECM. PD98059, an inhibitor of mitogen-activated protein kinase (MAPK) kinase activity, caused similar inhibitory effects. Taken together, these results suggest that tobacco smoke activated the EGFR-->extracellular signal-regulated kinase 1/2 MAPK pathway, causing induction of uPA. This led, in turn, to increased plasmin-dependent degradation of matrix proteins and enhanced cell migration through ECM. These data strongly suggest that chemicals in tobacco smoke can mimic the effects of oncogenes in regulating uPA-dependent cell invasion through ECM. These findings also strengthen the rationale for determining whether inhibitors of EGFR tyrosine kinase reduce the risk of tobacco smoke-related second primary tumors.

Association between different alcoholic beverages and leukoplakia among non- to moderate-drinking adults: A matched case–control study

While heavy drinking is a risk factor for oral leukoplakia, the effects of moderate drinking and of different alcoholic beverages are unclear and were investigated in this case-control study. 187 leukoplakia patients, aged 40-65 years, who were not heavy drinkers and did not change their drinking/smoking habits over the last decade, were age/gender matched to 187 controls. The effect of regular, moderate, overall alcohol, beer, wine, spirit drinking, adjusted for the effects of heavy smoking and other important co-variables, were assessed using conditional logistic regression analysis. Overall alcohol (OR, 0.22), wine (OR, 0.20), spirits (OR, 2.93) were significantly associated to leukoplakia. A statistically significant interaction wine/heavy smoking was also found. Such different effects could be explained by the ethanol antagonising potential of other drink components, such as polyphenols, abundant in red wine and scarce in spirits. Among heavy smokers, the preventive effect of wine was more than multiplicative.

Risk assessment of p53 genotypes and haplotypes in tobacco-associated leukoplakia and oral cancer patients from eastern Idia

The role of 3 p53 polymorphisms (16 bp duplication at intron 3, codon 72 Arg/Pro and intron 6 NciI RFLP at np 13494) as potential markers for indicating cancer risk remains inconclusive. In our case-control study consisting of 197 leukoplakia and 310 oral squamous cell carcinoma (SCC) patients and 348 controls, genotype frequencies at these 3 p53 loci were determined by PCR-RFLP method and analyzed by multiple logistic regression to determine the risks of the diseases. The 2/2 genotype at codon 72 of p53 was at risk for developing leukoplakia (OR = 1.6, 95% CI 1.1-2.3), whereas the combination of 1/2 and 2/2 genotypes at intron 3 and 1/1 and 1/2 genotypes at intron 6 conferred a protective effect against leukoplakia and oral SCC development, respectively (OR = 0.5, 95% CI 0.4-0.8 and OR = 0.6, 95% CI 0.5-0.9, respectively). When subjects were stratified according to specific tobacco habit, the risk/protection estimates improved significantly in some cases. Specifically, the exclusive smokers with p53 codon 72 2/2 genotype showed a higher risk of developing leukoplakia (OR = 2.7, 95% CI 1.2-6.3). Furthermore, a particular p53 haplotype 1-2-2 was at risk for both tobacco-associated leukoplakia and oral SCC (OR = 1.5, 95% CI 1.1-1.9 and OR = 1.3, 95% CI 1.1-1.7, respectively). Our results show that both specific p53 genotype and haplotype can indicate risk of tobacco-associated leukoplakia, but risk of development of tobacco-associated oral SCC can be predicted by specific p53 haplotype only.

Oral cancer: leukoplakia and squamous cell carcinoma

This article reviews the epidemiology, etiologic risk factors, clinical presentation, recognition, and diagnosis of oral precancer and cancer. The actual treatment and complications from treatment of oral cancer are discussed only briefly.

Need to educate primary caregivers about the risk factor profile of smokeless tobacco users

BACKGROUND

Many cancer risk factors are correlated with one another, and the presence of 1 risk factor may be a marker for other unhealthy behaviors. In this article, we focus on smokeless tobacco (ST), a known risk factor for oral leukoplakia and oral cancer, and the cancer risk factors associated with its use.

METHODS

We analyzed cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) I and the 1982-1984 NHANES I Epidemiologic Follow-up Study. Risk factor information was available on individuals 25-74 years of age, most of whom would be middle age or elderly today.

RESULTS

Older subjects, Black males, and those living in the Southern Unite States had the highest prevalence of ST use. ST use was associated with current smoking (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.5), former smoking (OR, 1.6; 95% CI, 1.4-2.0), low fruit and vegetable intake, low SES, increased alcohol consumption (among nonsmoking ST users), and increased body mass index, all of which elevate cancer risk. CONCLUSION. Physicians and dentists should ask their patients about current or former ST use. Identification of ST users should prompt the physician or dentist to inquire about other chronic disease risk factors that the patient may have and to educate the ST using patient about ways to reduce their risk of cancer.

Impact of betel quid, tobacco and alcohol on three-stage disease natural history of oral leukoplakia and cancer: implication for prevention of oral cancer

The natural history of the three-stage process from normal, oral leukoplakia to oral cancer in relation to betel quid chewing, smoking and drinking is rarely addressed. The aim of this study was to simultaneously quantify the effects of three risk factors on occurrence of oral leukoplakia and malignant transformation to oral cancer. A hospital-based case-control study design derived from three retrospective cohorts from 1988 to 1998 was conducted. A total of 74 oral cancer patients, 164 patients with oral leukoplakia and 187 controls were interviewed to collect information on their betel chewing, smoking and drinking habits. The effects of the three risk factors on the progression rates of the three-stage disease process were estimated using the three-state Markov model. Subjects who chewed betel quid were at greater risk of leukoplakia (adjusted odds ratio (OR) 17.7 (9.03-34.5)) but there was no significant effect on malignant transformation (OR 1.04 (0.61-1.76)). Smoking played a major role in the onset of leukoplakia (OR 4.26 (2.21-8.23)) but a minor role in malignant transformation (OR 1.36 (0.69-2.68)). Alcohol was positively associated with malignant transformation (OR 2.37 (1.47-3.82)) but unrelated to occurrence of leukoplakia (OR 0.76 (0.04-1.43)). We concluded that smoking and betel quid were two significant risk factors for the occurrence of leukoplakia, whereas alcohol was significantly responsible for malignant transformation.

[Clinical and mycological examinations of oral mucosa in cyclosporine A treated patients after renal transplantation]

Cyclosporine A (CsA) is one of the basic and often used immunosuppressive agents. It is used to prevent rejection of allogenic transplants and to cure many diseases with autoimmunological components. The development of transplantology and frequent presence of autoaggressive disorders causes increased use of CsA, which intensifies problem of side-effects. Gingival overgrowth, oral mucosa pathologies related with bacterial, viral and fungal infections and neoplasma are described as most frequent side-effects of cyclosporine A in the oral cavity. The aim of this study was to assess the frequency of presence of different types of oral mucosa lesions in cyclosporine A-treated patients after renal transplantation. Thirty renal transplant recipients aged 11-64 years (including 13 females and 17 males) with cyclosporine treatment period from 6 months to 10 years were examined. Pathological changes on the oral mucosa were noted in 18 patients (60%). The fungal infections were the most often observed pathology (46.7% of examined persons). In mycological tests Candida albicans was most often isolated. Other species: C. kefyr, C. parapsilosis and C. tropicalis were also found. In 4 cases cheilitis angularis was additionally diagnosed. In 16.7% of CsA-treated patients, pathological changes of epithelium with homogenic leucoplakia features were observed. Hypertrophic lesions of oral mucosa in 10% of cases and many small erosions of inflamed mucosa of hard palate in 1 case were also noted. Our observations show connection between incidence of oral mucosa pathologies and immunosuppressive treatment. This suggests that interdisciplinary cooperation is necessary for early start of prevention and treatment program.

Bile reflux as possible risk factor in laryngopharyngeal inflammatory and neoplastic lesions

Laryngopharyngeal reflux is now of major interest as an aetiologic factor in chronic inflammatory and neoplastic lesions of upper digestive tract. However, reports in the literature refer only to the irritating action of the acid component of reflux, while possible damaging action of other reflux components remains unknown. Aim of this study was to verify the hypothesis that alkaline-bile reflux could also be involved in onset of inflammatory, precancerous and neoplastic laryngeal lesions. A total of 40 consecutive gastrectomized patients coming to our Clinic from Gastroenterology Outpatient Unit for an anamnestic and clinical evaluation with videolaryngoscopy of upper digestive airways, entered the study. All presented bile or alkaline reflux as a direct consequence of gastroduodenal anastomosis (Billroth I) and gastrojejunal anastomosis (Billroth II) performed over a time span > 20 years. Oesophagogastroduodenoscopy revealed the presence of bile in the residual gastric cavity in all operated patients objectively confirming duodenogastric reflux. Examination of data showed that 3 patients (7.5%) had undergone CO2 laser cordectomy in the 3 years prior to the study for squamous cell laryngeal carcinoma, 3 patients (7.5%) had leukoplakia, 8 (20%) vocal cord chronic oedema with signs of chronic diffuse laryngitis, 6 (15%) posterior laryngitis, 8 (20%) interarytenoid oedema while only 12 (30%) showed no ENT lesions. Statistical analysis revealed a significant correlation between incidence of inflammatory and neoplastic laryngeal lesions and type of surgery (Billroth II and total gastrectomy) with respect to other types of gastric resection. There was also a significant increase in presence and severity of laryngopharyngeal lesions in relation to time elapsed after surgery. These results, although preliminary, seem to confirm that some components of reflux (duodenal content), other than the acid component, play a damaging role involved in the onset of multiple clinical signs and symptoms of laryngopharyngeal reflux disease. It is concluded that systematic use of bile measurement, together with 24-hour pH monitoring, is advisable in subjects with clinical signs and symptoms of laryngopharyngeal reflux, but unresponsive to classic medical treatment, and in gastrectomized patients in order to confirm, on larger series, this fascinating aetiopathogenetic hypothesis.

Prognosis of oral pre-malignant lesions: significance of clinical, histopathological, and molecular biological characteristics

The concept of a two-step process of cancer development in the oral mucosa, i.e., the initial presence of a precursor subsequently developing into cancer, is well-established. Oral leukoplakia is the best-known precursor lesion. The evidence that oral leukoplakias are pre-malignant is mainly derived from follow-up studies showing that between < 1 and 18% of oral pre-malignant lesions will develop into oral cancer; it has been shown that certain clinical sub-types of leukoplakia are at a higher risk for malignant transformation than others. The presence of epithelial dysplasia may be even more important in predicting malignant development than the clinical characteristics. Three major problems, however, are attached to the importance of epithelial dysplasia in predicting malignant development: (1) The diagnosis is essentially subjective, (2) it seems that not all lesions exhibiting dysplasia will eventually become malignant and some may even regress, and (3) carcinoma can develop from lesions in which epithelial dysplasia was not diagnosed in previous biopsies. There is, therefore, a substantial need to improve the histologic assessment of epithelial dysplasia or, since epithelial dysplasia does not seem to be invariably associated with or even a necessary prerequisite for malignant development, it may be necessary to develop other methods for predicting the malignant potential of pre-malignant lesions. As a consequence of these problems, numerous attempts have been made to relate biological characteristics to the malignant potential of leukoplakias. Molecular biological markers have been suggested to be of value in the diagnosis and prognostic evaluation of leukoplakias. Markers of epithelial differentiation and, more recently, genomic markers could potentially be good candidates for improving the prognostic evaluation of precursors of oral cancer. As yet, one or a panel of molecular markers has not been determined that allows for a prognostic prediction of oral pre-cancer which is any more reliable than dysplasia recording. However, these new markers could be considered complementary to conventional prognostic evaluation.

The role of acid and alkaline reflux in laryngeal squamous cell carcinoma

HYPOTHESIS

At present, main factors considered responsible for the onset of squamous cell carcinoma are tobacco smoking, alcohol abuse, and exposure to viral and toxic agents. In last years, great interest has been focused on gastroesophageal reflux as independent carcinogenic factor and co-carcinogen in association with smoking and alcohol assumption.

STUDY DESIGN

Initially, the aim of this study was to objectively evaluate the presence of distal and proximal esophageal reflux with multielectrode pH measurement in patients with cancer of the larynx and/or hypopharynx (group A). However, in the course of the study, pharyngolaryngeal cancer was also observed in 4 patients with achlorhydria; therefore, the hypothesis that alkaline reflux might be involved in the onset of laryngeal cancer was tested (group B).

METHODS

Twenty-one consecutive patients with laryngeal or hypopharyngolaryngeal squamous cell carcinoma (group A) entered the study. Twenty-one patients without laryngo-pharyngeal diseases were used as control subjects. A validated questionnaire of the clinical history was completed by all patients who underwent 24-hour pH monitoring. Group B included 40 consecutive gastrectomized patients (28 males and 12 females) in whom biliary or alkaline reflux was directly consequent to Billroth I or Billroth II operation. The control group was composed of 40 non-gastrectomized dyspeptic patients. The clinical history was controlled and obtained; EDGS and ENT examination with videolaryngoscopy was performed in all patients.

RESULTS

In group A, pH measurement showed pathological reflux in 80.9% (17 of 21) of patients with no typical symptoms in 63.7% of them. The difference was significant with respect to the control group. In group B, 6 of 40 (15%) had preneoplastic lesions or a history of laryngeal tumor. The difference was significant with respect to the control group. A total of 7.5% of group B patients had previously undergone CO2 laser cordectomy for laryngeal squamous cell carcinoma and 7.5% had leukoplakia. We found a significantly higher incidence (<.05) of neoplastic and preneoplastic disease of the larynx in patients undergoing Billroth II and total gastrectomy than in those undergoing Billroth I and Roux-en-Y resection. We also found a significant increase (<.01) in ENT lesions in the group of patients who had undergone gastrectomy more than 20 years previously.

CONCLUSIONS

In agreement with literature reports, results obtained in group A confirmed that gastroesophageal reflux is often present in patients with neoplastic lesions of the pharynx and larynx. Furthermore, gastric resection is indicated for the first time as an additional risk factor or cofactor of precancerosis and squamous cell carcinoma of the pharynx or larynx. Further studies are necessary to establish the cause and effect relationship between biliary reflux and pharyngo-laryngeal tumors.

[Lesions of the mouth mucosa. An anamnestic and clinical study of 100 consecutive patients with mucosal lesions]

The present study evaluates and analyzes anamnestic and clinical findings of 100 consecutively referred patients with oral mucosal lesions. The mean age of the cohort was 50.5 years (range 8-91 years) with a female rate of 60 percent. A total of 9 malignant neoplasia were found among the 100 mucosal lesions, including 7 squamous cell carcinomas and 2 mucoepidermoid carcinomas. In addition, 11 cases presented with leukoplakia and 4 cases with lichen planus, both recognized as possible precancerous conditions. These figures support the essential role of the dentist with respect to initial diagnosis and prevention of oral cancer. In addition, stomatologic follow-up examinations are recommended to be performed by each and every general practitioner. In the near future, the dentist will assess oral mucosal lesions more frequently due to the increasing number of elderly patients and to the fact that elderly people present with more lesions compared to younger patients. consistent to literature data, patients with leukoplasia and squamous cell carcinoma had the highest rates of tobacco and alcohol consumption. Therefore, the dentist may also become active in giving preventive information to the patient. the results of the present study showed, that--by employing a standardized examination--a correct clinical diagnosis was identical to the final diagnosis established by laboratory techniques.

[The diagnosis and treatment of background and precancerous diseases of the vulva]

Methodological approaches have been developed toward raising the informative value of cytological diagnosis. There have been identified pathogenetic variants of background and precancerous affections of the vulva, their leading factors being viral infection, function disorders of the hypothalamic centres, hypoestrogenemia, hepatic and thyroidal abnormalities. The effectiveness of the treatment scheme developed with taking account of the above-stated items is 97.3%.

Levels of proteolytic activities as intermediate marker endpoints in oral carcinogenesis

It is essential to identify intermediate marker endpoints of carcinogenesis for the evaluation of the effectiveness of cancer-chemopreventive agents. We have observed that levels of proteolytic activities (as detected by 4 different substrates) are increased 2-3-fold (P < 0.003) in oral buccal mucosa cells of smokers and patients with oral leukoplakia or erythroplakia as compared to a nonsmoking comparison group. In addition, proteolytic activity levels in the buccal cells were increased nearly 3-fold in patients with oral trauma (P < 0.01) or diabetes (P < 0.02), as well as pregnant women (P < 0.04). Excluding these subgroups of patients in epidemiological studies increase the differences in levels of proteolytic activities between both the nonsmoking comparison group and smokers and between the comparison group and patients with oral leukoplakia or erythroplakia. Evaluation of prerandomization levels of proteolytic activities of patients in cancer chemoprevention trials will increase the statistical power by allowing stratified randomization based on levels of proteolytic activities. The observed increases in levels of proteolytic activities in tissues at higher than normal risk of cancer development suggest that levels of proteolytic activities should be used as immediate marker endpoints in human cancer prevention trials using protease inhibitors as potential anticarcinogenic agents.

Increased prevalence of dysplastic and malignant lip lesions in renal-transplant recipients

BACKGROUND

Renal-transplant recipients are known to have increased rates of skin cancer associated with exposure to the sun. Little is known, however, about the prevalence and histologic features of lesions of the lips in these patients, or about risk factors for such lesions.

METHODS

We examined the lips of 160 renal-transplant recipients (105 men and 55 women; mean [+/- SD] age, 48 +/- 13 years) and 160 normal subjects matched with the transplant recipients for age, sex, and skin type. The mean length of time between transplantation and the examination was 69 +/- 52 months; 58 percent of the recipients had received their grafts more than 60 months earlier.

RESULTS

Among the 160 renal-transplant recipients, 21 (13 percent) had leukoplakia; in 2 (1.2 percent) the leukoplakia contained squamous-cell carcinoma. In contrast, only one normal subject (0.6 percent) had leukoplakia. Histologically, 13 of the 21 leukoplakias (62 percent) in the renal-transplant recipients who underwent biopsy were dysplastic, and 2 (10 percent) contained squamous-cell carcinoma. Actinic change was evident in 91 percent of the dysplastic lesions but not in the nondysplastic lesions (P < 0.001). Exposure to the sun and smoking were risk factors for dysplastic and malignant lip lesions in the renal-transplant recipients (P < 0.001 and P = 0.003, respectively). Among these recipients, only men had dysplastic or malignant lip lesions (P = 0.006); lipstick was used frequently by 73 percent of the women. The clinical appearance of lip lesions did not predict the presence of dysplasia or cancer.

CONCLUSIONS

Renal-transplant recipients have an increased prevalence of leukoplakia, dysplasia, and cancer of the lip.

The association of clinical conditions and serologic tests with CD4+ lymphocyte counts in HIV-infected subjects without AIDS

Early intervention guidelines in HIV infection require knowledge of CD4+ lymphocyte count; however, CD4+ determinations require special laboratory procedures and may not be readily available in all situations. Using data from 207 HIV-seropositive homosexual men without AIDS, we evaluated the association of difference clinical conditions or serologic tests with CD4+ count. Men with conditions including seborrheic dermatitis, hairy leukoplakia, oral candidiasis and chronic diarrhea, and men with beta2-microglobulin levels greater than or equal to 4.0 mg/l had significantly lower CD4+ counts. However, the probability that a subject with such parameters had less than 200 x 10(6)/l CD4+ cells was limited (25-63%). Although the probability that a subject with such parameters had less than 500 x 10(6)/l CD4+ cells was better (76-88%), the probability that a person without these parameters had greater than or equal to 500 x 10(6)/l CD4+ cells was only 45-50%. Clinical and serologic parameters may provide important prognostic information, but cannot be used to reliably determine the level of CD4+ cells.

[Bladder leukoplakia]

Leukoplakia of the bladder is a rare condition. It is characterized by squamous metaplasia of the transitional epithelium and keratinization. The etiology and possible pathogenetic factors are discussed. Up to 42% develop carcinoma which makes early diagnosis important. The clinical diagnosis is difficult. The patients present with symptoms of vesical irritation and the passage of flakes is pathognomonic. Diagnosis is made by cystoscopy with biopsies. Characteristic cystoscopic findings are described. Treatment and a follow-up programme are outlined. As conservative treatment remains unsatisfactory radical extirpation or cystectomy is recommended for extensive lesions.

Thermally induced 'nicotine' stomatitis. A case report

A palatal lesion resembling "nicotine" stomatitis was found in a woman who did not smoke. However, the patient frequently drank extremely hot beverages. After she was instructed to reduce the temperature of the beverages, the lesion almost completely resolved. This suggests that heat was the primary cause of this lesion and also implicates heat as the major cause of nicotine stomatitis.

Acquired immunodeficiency syndrome and Epstein-Barr virus

Epstein-Barr virus is an important aetiological factor in certain HIV-related syndromes, with its opportunist expression related to the level of host immunodeficiency. In asymptomatic people co-infected with HIV, EBV activity is reflected by increased viral shedding and rises in anti-EBV titres; as immunodeficiency ensues EBV manifests as epithelial hyperproliferation in OHL, and later as B-cell lymphoma in AIDS. The suggested role of EBV as a co-factor in the progression of HIV infection and development of AIDS has not been established, although another herpesvirus, cytomegalovirus, might play such a role. Advances in our understanding of HIV regulation and its interaction with other latent (herpes) viruses should provide important molecular and pharmacological approaches to the clinical management of advanced HIV disease.

[Two cases of oral leukoplakia possibly associated with human papillomavirus]

Two cases of oral leukoplakia were studied immunohistologically and ultrastructurally. By means of avidin-biotin peroxidase complex technique using papillomavirus specific antibody, distinct nuclear staining of epithelial cells of middle and upper layers was observed in both cases. Further evidence for the presence of human papillomavirus was obtained by the electron micrograph, which revealed virus-like particles (30-40 nm in diameter) within the nucleus.

Possible mycological etiology of oral mucosal cancer: catalytic potential of infecting Candida albicans and other yeasts in production of N-nitrosobenzylmethylamine

Yeasts were isolated from 12 cases of oral precancerous lesions (leukoplakia and erythroleukoplakia) by sampling the lesion as well as normal mucosa of each patient, yielding 21 strains of Candida albicans belonging to 15 biotypes, two strains of C. tropicalis, one strain of C. parapsilosis and two strains of Torulopsis glabrata. Biopsies were obtained from the lesions for histologic examination. The catalytic potential of the yeast strains to form N-nitrosobenzylmethylamine (NBMA) from the precursors N-benzylmethylamine and nitrite was assessed at pH 6.8. The NBMA produced was identified and quantitated by h.p.l.c. and confirmed by g.c.-m.s. Nitrosation rates were calculated as total nitrosamine subtracted the chemically produced nitrosamine, and related to number of yeast cells. The yeast strains differed in nitrosation potential (P less than 0.001), ranking from 0 to 1.2 micrograms NBMA/10(6) cells. Candida albicans strains, belonging to the biotypes 051, 147, 151, 153, 157 and 353, which constitute more rarely occurring biotypes, exhibited the highest nitrosation potential. Candida tropicalis, C. parapsilosis and T. glabrata were ranked lower. Strains with high nitrosation potential were generally isolated from lesions with more advanced precancerous changes. The yeast cells were present in the superficial part of the epithelium of the lesions as branching mycelium, and in some cases extending from the mucosal surface to the deeper epithelial cell layers. This might represent a fungal transportation system which could channel precursors in the saliva at the mucosal surface to the deeper part of the epithelium where the produced nitrosamine could be deposited. Thus, further evidence is provided supporting the hypothesis that certain strains of C. albicans and of other yeasts play a causal role in the development of oral cancer, by means of endogenous nitrosamine production.

Oral candidiasis

Candidiasis is, by far, the most common mycotic infection of the human oral cavity. The usually manifested clinical expression of oral candidiasis at all ages from the newborn to the elderly is thrush. Other forms that affect the mouth include acute atrophic candidiasis associated with oral antibiotic therapy, chronic atrophic candidiasis attributable to the wearing of full upper dentures, candidal cheilosis ascribable to perlèche or decreased vertical dimension in the lower third of the face, chronic mucocutaneous candidiasis emanating from a T-lymphocyte deficiency, and candidal leukoplakia. Extensive use of antibiotics and immunosuppressive drugs have greatly increased the number of Candida-induced oral infections. Patients debilitated by irradiation, cancer chemotherapy, organ transplants, diabetes mellitus, and defects in cell-mediated immunity are particularly vulnerable. Fortunately, the vast majority of cases of oral candidiasis are not life-threatening and readily respond to appropriately administered anticandida agents. It must always be remembered, however, that the organism has the capacity to produce fulminating fatal infection by hematogenous dissemination from seemingly innocuous oral infections that serve as a portal of entry to the systemic circulation. Consequently, all oral candidal infections in compromised patients must be treated vigorously and effectively.

Smokeless tobacco and oral cancer: a cause for concern?

Until recently, the use of smokeless tobacco had been restricted to a relatively small percentage of the United States population. The increased promotion and use of both snuff and chewing tobacco raise the question: What effect will such habits have on oral disease and the incidence of oral cancer? Although information for the US is sparse, extensive epidemiologic data are available from India, where the use of tobacco is prevalent and the incidence of oral cancer very high. The Indian data suggest that oral cancer and precancerous lesions occur almost solely among those with tobacco habits, the rate of malignant transformation of precancerous lesions is not greater than in the West, the relative risk of developing oral cancer is similar in India and in the US, and this risk rises with duration of use. Thus, it seems likely that increased usage of smokeless tobacco in the US will eventually lead to an increased incidence of precancerous and cancerous oral lesions in Americans.

Cryosurgery in the treatment of lichen sclerosus et atrophicus of the vulva

Twelve patients with lichen sclerosus et atrophicus of the vulva were treated by a nitrous oxide cryoprobe. All had had severe itching which was relieved in the post-operative period in 75% and for 3 years in 50%. Eight had histologically proven leukoplakia which cleared post-operatively in five (62.5%) and remained clear at three years in four (50%). In one patient pruritus, leukoplakia and ultimately squamous carcinoma appeared.