Recurrent Oral Squamous Cell Carcinoma Research Articles

Analysis of p16INK4A expression of oral squamous cell carcinomas in Taiwan: Prognostic correlation without relevance to betel quid consumption

In this study, we examined the role of p16(INK4A) , a surrogate biomarker of HPV-related head and neck cancers with better prognosis, in an endemic area of betel quid (BQ)-related oral squamous cell carcinoma (OSCC). p16(INK4A) immunohistochemistry was examined in 165 OSCCs, statistical analyses were performed to elucidate the correlation between p16(INK4A) expression and BQ habits/pathologic features, and the prognostic impact of p16(INK4A) and different parameters were analyzed. The incidence of p16(INK4A) expression was similar between BQ chewers and non-chewers. p16(INK4A) expression was significantly associated with nodal metastasis (P = 0.005). There was a trend suggesting that the loss of p16(INK4A) expression was more frequent in higher T stages, however, this was found only in patients without lymph node metastasis (P = 0.059). A poorer prognosis and a higher risk of tumor recurrence were found in OSCCs without p16(INK4A) expression. (The HR for cancer-specific mortality and cancer recurrence was 3.55 and 1.89, respectively.) Although it has been suggested that BQ chewers had a greater tendency toward tumor recurrence and poor outcome, our data demonstrated that p16(INK4A) expression is unrelated to BQ habit and that p16(INK4A) downregulation is a strong predictor for OSCC progression, recurrence and survival in Taiwan.

Increased serum placenta growth factor level is significantly associated with progression, recurrence and poor prognosis of oral squamous cell carcinoma

We recently found that the expression of placenta growth factor (PlGF) in oral squamous cell carcinoma (OSCC) specimens is correlated with the progression and prognosis of OSCC. In this study, serum samples were obtained from 72 OSCC patients before and 3 months after surgical cancer excision and from 30 normal controls. Serum PlGF levels were determined by enzyme-linked immunosorbent assay (ELISA). The mean serum PlGF levels were significantly higher in pre-surgery OSCC patients than in normal controls (19.1±10.7 vs. 10.1±4.5, P<0.001). Serum PlGF levels dropped to near the normal control levels after surgical cancer removal. Higher pre-surgery serum PlGF levels were significantly associated with larger tumor size (P=0.015), positive lymph node metastasis (P=0.001), more advanced clinical stages (P=0.002), and loco-regional recurrence (P=0.037). The serum PlGF level was identified as an independent unfavorable prognosis factor by multivariate Cox regression analyses (P=0.014). Kaplan-Meier curve showed that OSCC patients with a higher serum PlGF level had a significantly poorer cumulative recurrence-free survival than those with a lower serum PlGF level (log-rank test, P=0.009). When we used the serum PlGF level of 19.1 pg/ml (mean normal control value plus 2 standard deviations) as a cutoff point, the sensitivity, specificity, and positive predictive value for tumor recurrence was 80%, 56% and 78%, respectively. We conclude that the serum PlGF level may be a valuable biomarker for prediction of therapeutic effect, progression, recurrence and prognosis of OSCC.

Role of tumor markers in oral squamous cell carcinoma: Review of literature and future consideration

Sensitive and reliable early diagnostic markers for oral squamous cell carcinoma (OSCC) remain unavailable. Early identification of recurrence for OSCC is also a challenge. This article reviews the recently identified biomarkers for OSCC such as cytokeratins, p53, tumor necrosis factor alpha (TNF-α), etc., which are of great utility in early diagnosis. In addition, the biomarkers that have been correlated with OSCC tumor malignancy by molecular pathology analysis are also described. This article speaks about selected reaction monitoring (SRM) which might even be applied to monitor differential expression of tumor proteins in blood, saliva, or fresh frozen tissue materials. SRM technique may complement or possibly replace western blotting for biomarker verification and for selection of potential biomarker candidates. This article may help to identify the potential biomarkers for screening and the molecular pathology analysis for high-risk patients of OSCC. Effective screening to identify high-risk patients will allow clinicians to provide an early and appropriate treatment to patients without delay and also reduce the risk of recurrence of OSCC.

A Study of Epidemiologic and Recurrence Factors of Oral Cancer

To analyze the epidemiologic characteristics and recurrence factors of oral squamous cell carcinoma (OSCC) in northwest China. Patients with OSCC whose first visits to the Stomatology Hospital of the Fourth Military Medical University from January 2007 through December 2008 were investigated. The epidemiologic risk factors and recurrence of OSCC were studied with logistic regression and a Cox regression model. The mean age of all 414 patients with OSCC was 58.16 ± 9.92 years; 67.15% were men, 43.24% were cigarette smokers, and 26.09% came from rural areas. In addition, 49.03% of these patients were diagnosed at an early stage. One hundred forty-seven patients developed recurrence of the disease, and the median progression-free survival was 7.3 months (range, 1.1 to 32.5 mo). The recurrence rate was approximately 35.5%. The study indicated that smoking habit, older age, and living in rural areas were the high-risk epidemiologic factors for OSCC. Smoking habit and late clinical stage were the high-risk factors for the recurrence of OSCC.

Significant association of SRC protein expression with the progression, recurrence, and prognosis of oral squamous cell carcinoma in Taiwan

Src protein overexpression correlates with progression and prognosis of a variety of human cancers. This study used immunohistochemistry to examine the expression of Src protein in 93 specimens of oral squamous cell carcinoma (OSCC). We found a significant association of high expression of Src protein (labeling indices >50%) with larger tumor size (p = .017), positive lymph node metastasis (p = .030), more advanced clinical stages (p = .007), and recurrence (p < .001) of OSCC. High expression of Src protein was identified as an independent unfavorable prognosis factor by multivariate Cox regression analysis. The Kaplan-Meier curve showed that patients with OSCC with high expression of Src protein had a significantly poorer cumulative survival than those with low expression of Src protein (log-rank test, p = .00267). The expression of Src protein is significantly associated with the progression, recurrence, and prognosis of OSCCs in Taiwan.

Poster 08: Salvage Surgery for Recurrent Squamous Cell Carcinoma of the Tongue

Poster 08: Salvage Surgery for Recurrent Squamous Cell Carcinoma of the Tongue

Salivary endothelin-1 potential for detecting oral cancer in patients with oral lichen planus or oral cancer in remission

Endothelin-1 (ET-1) is a potent vasoconstrictor involved not only in vascular biology but also in carcinogenesis. Results of a study in 2007 suggested salivary ET-1 as a potential biomarker for oral squamous cell carcinoma (OSCC), but a later study showed conflicting results. The purpose of our pilot study was to investigate feasibility of using salivary ET-1 as a biomarker for OSCC in two groups: oral lichen planus (OLP) patients and patients with OSCC in remission. Saliva samples were collected from five groups of subjects: patients with newly diagnosed, active OSCC (Group A); patients with OSCC in remission (Group B); patients with active OLP lesions (Group C); patients with OLP in remission (Group D); and normal controls (Group E). Salivary ET-1 levels were determined by enzyme-linked immunosorbent assay, and the results were analyzed by the Mann-Whitney U test. The mean salivary ET-1 level in Group A was significantly higher than that found in Group C (p=0.001), Group D (p=0.015) or Group E (p=0.004). There were no significant differences (p>0.05) in the mean salivary ET-1 levels between Groups A and B; Groups B and C; Groups B and D; Groups B and E; Groups C and D; Groups C and E; or Groups D and E. Salivary ET-1 could be a good biomarker for OSCC development in OLP patients regardless of the degree of OLP disease activity. However, it appeared not to be a good biomarker for detecting recurrence of OSCC in patients in remission.

MUC4: A novel prognostic factor of oral squamous cell carcinoma

MUC4 mucin is now known to be expressed in various normal and cancer tissues. We have previously reported that MUC4 expression is a novel prognostic factor in several malignant tumors; however, it has not been investigated in oral squamous cell carcinoma (OSCC). The aim of our study is to evaluate the prognostic significance of MUC4 expression in OSCC. We examined the expression profile of MUC4 in OSCC tissues from 150 patients using immunohistochemistry. Its prognostic significance in OSCC was statistically analyzed. MUC4 was expressed in 61 of the 150 patients with OSCC. MUC4 expression was significantly correlated with higher T classification (p = 0.0004), positive nodal metastasis (p = 0.049), advanced tumor stage (p = 0.002), diffuse invasion of cancer cells (p = 0.004) and patient's death (p = 0.004) in OSCC. Multivariate analysis showed that MUC4 expression (p = 0.011), tumor location (p = 0.032) and diffuse invasion (p = 0.009) were statistically significant risk factors. Backward stepwise multivariate analysis demonstrated MUC4 expression (p = 0.0015) and diffuse invasion (p = 0.018) to be statistically significant independent risk factors of poor survival in OSCC. The disease-free and overall survival of patients with MUC4 expression was significantly worse than those without MUC4 expression (p < 0.0001 and p = 0.0001). In addition, the MUC4 expression was a significant risk factor for local recurrence and subsequent nodal metastasis in OSCC (p = 0.017 and p = 0.0001). We first report MUC4 overexpression is an independent factor for poor prognosis of patients with OSCC; therefore, patients with OSCC showing positive MUC4 expression should be followed up carefully.

USC-HN2, a new model cell line for recurrent oral cavity squamous cell carcinoma with immunosuppressive characteristics

Head and neck squamous cell carcinomas (HNSCC) are common and aggressive tumors that have not seen an improvement in survival rates in decades. These tumors are believed to evade the immune system through a variety of mechanisms and are therefore highly immune modulatory. In order to elucidate their interaction with the immune system and develop new therapies targeting immune escape, new pre-clinical models are needed. A novel human cell line, USC-HN2, was established from a patient biopsy specimen of invasive, recurrent buccal HNSCC and characterized by morphology, heterotransplantation, cytogenetics, phenotype, gene expression, and immune modulation studies and compared to a similar HNSCC cell line; SCCL-MT1. Characterization studies confirmed the HNSCC origin of USC-HN2 and demonstrated a phenotype similar to the original tumor and typical of aggressive oral cavity HNSCC (EGFR(+)CD44v6(+)FABP5(+)Keratin(+) and HPV(-)). Gene and protein expression studies revealed USC-HN2 to have highly immune-modulatory cytokine production (IL-1β, IL-6, IL-8, GM-CSF, and VEGF) and strong regulatory T and myeloid derived suppressor cell (MDSC) induction capacity in vitro. Of note, both USC-HN2 and SCCL-MT1 were found to have a more robust cytokine profile and MDSC induction capacity when compared to seven previously established HNSCC cell lines. Additionally, microarray gene expression profiling of both cell lines demonstrate up-regulation of antigen presenting genes. Because USC-HN2 is therefore highly immunogenic, it also induces strong immune suppression to evade immunologic destruction. Based upon these results, both cell lines provide an excellent model for the development of new suppressor cell-targeted immunotherapies.

Oral Squamous Cell Carcinoma: Clinicopathological Features in Patients with and without Recurrence

Aim: To compare the clinicopathological profile of oral squamous cell carcinoma (OSCC) in groups with and without recurrence. Methods: Records of all patients who underwent surgery for primary OSCC at a single institution during 1999 were identified. Patient demographics, lesion site, clinical and pathologic stage, pathologic grading, pattern of invasion, lymphocytic infiltrate, perineural invasion, and treatment and survival data were collected. Descriptive statistics were calculated for each variable and survival was calculated using Kaplan-Meier and Cox models. Patients were divided into 2 groups: with (n = 25) and without (n = 28) recurrence. Results: Tongue (p = 0.02) and poorly differentiated (p = 0.04) tumors were associated with recurrence. Kaplan-Meier and Cox models revealed tobacco use and the absence of lymphocytic infiltrate to be associated with the poorest survival in recurrent OSCC. Conclusion: The tumor site, tobacco use, and pathological features were involved in the recurrence of OSCC and should be taken into account for OSCC treatment and follow-up.

Predictive value of high Ki‐67 expression in stage I oral squamous cell carcinoma specimens after primary surgery

Until now prognostic evaluation for patients with oral squamous cell carcinoma (OSCC) remains difficult. Thus, the aim of the present study was to ascertain the value of Ki-67 expression in predicting locoregional recurrence in OSCC. In a large, homogeneous study population consisting of 166 patients with OSCC exclusively treated with primary surgery, expression of Ki-67 was investigated by immunohistochemistry. We report that high proliferation significantly correlated to a higher risk of locoregional recurrence in stage I OSCC patients (p = .029). Carcinomas with a Ki-67 labeling index above the median showed a mean time to recurrence of 42 months, whereas mean time to recurrence was 55 months for those tumors below the median (p = .017). This study provides the evidence of a predictive value of Ki-67 expression in stage I OSCC. Therefore, Ki-67 expression level could be used to identify a subgroup of surgically treated patients with stage I OSCC who might benefit from treatment intensification.

Markedly increased Oct4 and Nanog expression correlates with cisplatin resistance in oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) is the sixth most prevalent cancer worldwide. Cancer stem cells (CSC) model theoretically contribute to tumor growth, metastasis, and chemo-radioresistance. Cisplatin is a widely used chemotherapeutic agent for OSCC treatment. The aim of this study was to compare stemness genes expression in chemo-sensitive and chemo-resistant specimens and further explore the potential markers that may lead to induce chemo-resistance in OSCC. The study method is the treatment of OC2 cells with cisplatin select cisplatin-resistant OC2 cells. Self-renewal ability was evaluated by cultivating parental and cisplatin-resistant OC2 cells within sphere-forming assay after serial passages. Differential expression profile of stemness markers between parental and cisplatin-resistant OC2 cells was elucidated. The parental and cisplatin-resistant OC2 cells were assessed for migration/invasion/clonogenicity tumorigenic properties in vitro. Expression of stemness markers in chemo-sensitive and chemo-resistant patients with OSCC was performed by immunohistochemistry staining in vivo. Sphere-forming/self-renewal capability was increased in cisplatin-resistant OC2 cells. Cisplatin-resistant OC2 cells highly expressed the stemness markers (Nanog, Oct4, Bmi1, CD117, CD133, and ABCG2). Furthermore, cisplatin-resistant OC2 cells increased migration/invasion/clonogenicity ability. Notably, up-regulation of Oct4 and Nanog expression was significantly observed in cisplatin-resistant patients with OSCC (**P < 0.01). These data indicate that cancer stem-like properties were expanded during the acquisition of cisplatin resistance in OSCC. Clinically, oral cancer stemness markers (Oct4 and Nanog) overexpression may promote the OSCC's recurrence to resist cisplatin.

Increase of ZASC1 gene copy number in recurrent oral carcinoma

The chromosome 3q26 locus is a hotspot region carrying oncogenes that frequently altered in neoplasms. ZASC1 is a zinc finger protein transcription factor localized on 3q26. Our previous study showed the frequent amplification of 3q26, including the ZASC1 gene, in oral squamous cell carcinoma (OSCC). This study investigated the copy number changes of ZASC1 gene from primary to recurrent OSCC and the functions of ZASC1 in OSCC cells. A total of 27 OSCC patients with primary and recurrent tumors were examined for ZASC1 and TERC copy number changes using Quantitative PCR analysis. Exogenous expression and knockdown of ZASC1 were carried out to specify the oncogenic potential of ZASC1 in OSCC cells. A ZASC1 copy number that has increased from primary to recurrent tumor counterparts in tissue pairs suggested the importance of ZASC1 in tumor progression. The increase of ZASC1 gene copy number in recurrent tumors was associated with the consumption of betel quid in patients. OSCC cells expressing ZASC1-FLAG fusion protein showed increased proliferation. After the knockdown of endogenous ZASC1 expression using small interference RNA, the growth and colony formation of SAS OSCC cells decreased. The findings support the hypothesis that ZASC1 localized on 3q26 contributes to the recurrence of OSCC.

Oral cavity squamous cell carcinoma survival by biopsy type: a cancer registry study

Biopsy of a suspected oral squamous cell carcinoma (SCC) is important for diagnosis. Concerns have been raised about the potential for tumour spread by incisional biopsy techniques. This study aimed to investigate the five-year survival and recurrence of oral SCC after incisional and excisional biopsy in total population data available from the Western Australian Cancer Registry (WACR). Total population data from the WACR, comprising all primary oral SCC cases diagnosed between 1990 and 1999, were examined. Information extracted included date of birth, gender, biopsy date, biopsy type, disease stage (TNM classification), disease site, date of recurrence and date of death. Records were excluded if the diagnosis was fine needle aspiration based, was not that of oral SCC and if a history was noted of another malignant neoplasm. Incisional and excisional biopsy cases were compared for five-year survival, adjusting for disease stage. No association was found between biopsy type and five-year survival or recurrence amongst individuals with Stage I or II disease. In this study, biopsy type was not associated with survival of oral SCC patients with Stage I or II disease, adding to the evidence that incisional biopsy of oral SCC can be a safe procedure.

Caspase expression in oral squamous cell carcinoma

Apoptosis is a genetically programmed form of cell death, of which caspases are the central components. By tissue microarray of 229 cases of oral squamous cell carcinoma (OSCC), we analyzed the immunoexpression of caspases 3, 6, 7, 8, 9, and 10. All proteins that we examined were expressed in primary OSCC samples. Caspases 8 and 9 were prominently expressed, and caspases 3, 6, 7, and 10 were occasionally expressed. Disease-free survival differed significantly between caspase 7 high-expressing and low-expressing patients, and our multivariate analysis suggested that expression of caspase 7 is an independent prognostic factor for patients with OSCC. This study suggests that caspases regulate the tumorigenesis of OSCC and that caspase 7 expression is a predictor of locoregional recurrence of OSCC.

Prediction of recurrence using exfoliative cytology and melanoma‐associated antigen‐A mRNA analysis following wide excision of oral squamous cell carcinoma: short report

Oral squamous cell carcinoma (OSCC) is the sixth most common cancer. The local recurrence of OSSC might result from the existence of occult cancer cells around tumour margins. Exfoliative cytology has lately gained great importance as a method for obtaining RNA samples from suspicious oral mucosal lesions in order to carry out molecular diagnosis. In addition, melanoma associated-A antigens (MAGE-A) are expressed in various tumours and their detection is a highly accurate sign that cancer cells are present. The prediction of a recurrence using MAGE-A mRNA expression analysis to follow-up OSCC cases using a newly established molecular diagnostic technique applied to cytological materials. RNA was extracted from three recurrent OSCC cases and from 20 healthy volunteers as a control group using a cytobrush. The expression of MAGE-A3, A4, A6, A10 and A12 was investigated in these specimens using quantitative real-time (RT-PCR). There was no expression of MAGE-A in the specimens of normal oral mucosa. However, the expression analysis of five different MAGE-A genes indicated a high potential for malignant change in biopsy-proven recurrent OSCC cases. Except for MAGE-A10, the rest of the genes were expressed in different ratios by the three recurrent cases, which had been determined on histopathology to be OSCC or carcinoma in situ. It is suggested that analysis of MAGE-A expression may be used as a risk prediction method in the diagnosis of recurrence after wide excision of OSCC to enhance the accuracy of exfoliative cytology, which has limitations due to false negative and false positive results.

Association between the polymorphisms in exon 12 of hypoxia-inducible factor-1α and the clinicopathological features of oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) is a common malignancy. The incidence of OSCC is particularly high in some Asian countries because of the popularity of the habit of chewing areca. Hypoxia-inducible factor-1alpha (HIF-1alpha) is up-regulated in the hypoxic microenvironment to enhance tumor survival. Five polymorphisms have been identified in exon 12 of HIF-1alpha including the C1772T polymorphism causing P582S, and the G1790A polymorphism causing A588T of the HIF-1alpha protein. This study investigated the relationship between these functional polymorphisms and the risk of progression of OSCC. PCR and direct sequencing were utilized to compare the genotypic polymorphism and allelic frequency of HIF-1alpha in 96 normal controls and 305 OSCC patients. No statistically significant difference in C1772T and G1790A genotypes and allelic frequency between control and OSCC patients was found. However, multivariate analysis indicated that the A carrier of HIF-1alpha G1790A in OSCC patients was significantly higher in larger tumors than in the contrasting group with an adjusted odds ratio of 2.92. The T carrier of HIF-1alpha C1772T in buccal cancer patients was significantly higher in the non-areca-chewing group with an adjusted odds ratio of 0.111. The buccal cancer patients with C1772T or G1790A had lower recurrence frequency with an odds ratio of 0.266. These findings may suggest a correlation between the HIF-1alpha C1772T and G1790A polymorphisms and the growth of OSCC, and the decrease of OSCC recurrence frequency.

Changes in peripheral blood lymphocyte phenotypes distribution in patients with oral cancer/oral leukoplakia in Taiwan

Oral squamous cell carcinoma (OSCC) is common in many Asian countries. The immunopathogenesis of OSCC is unclear. The authors analyzed the lymphocyte subtypes and surface activation markers in healthy Taiwanese people (n=130) and patients with OSCC (n=97)/oral leukoplakia (OL, n=28) using flow cytometry. Univariate analysis found an elevation in the percentage of CD56+ NK cells, CD4+/CD69+ T cells, CD19+/CD69+ B cells and CD56+/CD69+ NK cells in OSCC patients relative to healthy people. The CD19+ and CD19+/CD25+ lymphocyte subtypes decreased in OSCC patients. CD56+ NK cells increased in OL patients. CD56+/CD69+ NK cells were elevated in recurrent and advanced OSCC. Multivariate analysis revealed an increase in CD56+ NK and CD19+/CD69+ cells in OL patients relative to controls. CD19+ B cells declined during progression from OL to OSCC. Betel quid chewing, alcohol, smoking, tumour location and staging showed little effect on lymphocyte subtypes. These results suggest that alterations and activation of NK cells, T and B cells are important and associated with disease status in oral carcinogenesis.

The role of tumor invasion into the mandible of oral squamous cell carcinoma

The aim of this study was to determine the prognostic impact of the extent of bone invasion in patients undergoing mandibulectomy for oral squamous cell carcinoma (OSCC), and to evaluate the relation between clinicopathologic parameters and outcome. Nine hundred and eighty-two patients presented with OSCC and 334 were treated surgically by some form of mandibular excision. Treatment included marginal, rim, or segmental mandibulectomy depending on the clinical and radiological observation of the mandible and suspected bone invasion. Kaplan-Meier plots and univariate log-rank test and multivariate Cox proportional hazards regression models were used to determine the association between possible predictor variables and survival time. After controlling for age, tumor and nodal stage, UICC stage, type of reconstruction, which were independent predictors of survival, type of mandibulectomy was significantly associated with survival in the univariate analysis (P = 0.038), whereas bone invasion was not in both univariate and multivariate analysis. The rate of bone invasion detected after marginal mandibulectomy was 15.5%, in rim resections 50%, and segmental mandibulectomy at 84.7%. Recurrence of OSCC was found to be associated with overall survival (P = 0.039). If bone invasion is identified histologically in a resected specimen, the prognosis is not worsened and additional surgery need not be undertaken in adequately resected margins. Although the mandible should be preserved if feasible, the choice of treatment should always provide safe resection margin. The high rates of unsuspected bone invasion found in this study should be kept in mind in patients with OSCC close to the mandible.

Removal of an oral squamous cell carcinoma including parts of osseointegrated implants in the marginal mandibulectomy. A case report

PurposeThe incidence of oral squamous cell carcinomas (OSCC) arising around dental implants will increase because of the rising popularity of dental implants. In this case, a novel surgical treatment of an OSCC in the vicinity of endosseous implants is reported.Materials and methodsIn a 69-year-old woman, a recurrent OSCC (cT2N0M0) developed in the floor of the mouth extending to the attached keratinized peri-implant mucosa of both interforaminal-placed dental implants. Radiographically, no bone invasion could be observed.ResultsTo radically remove the tumor, a marginal mandibulectomy was performed including the cranial parts of both dental implants by cutting them into two parts. Three years after tumor resection and one year after reimplantation, the patient is disease free and has a good oral function.ConclusionsIn case of an OSCC, traditional bone and soft margins for oncologic safety are 1.0 cm. If a dental implant is present within this safety zone, on condition, there is no massive bone invasion, and the original mandible has sufficient vertical height; a marginal mandibulectomy including part of the implants can be considered.