Tahwinder Upile

Stromal features are predictive of disease mortality in oral cancer patients

Worldwide, approximately 405 000 cases of oral cancer (OSCC) are diagnosed each year, with a rising incidence in many countries. Despite advances in surgery and radiotherapy, which remain the standard treatment options, the mortality rate has remained largely unchanged for decades, with a 5‐year survival rate of around 50%. OSCC is a heterogeneous disease, staged currently using the TNM classification, supplemented with pathological information from the primary tumour and loco‐regional lymph nodes. Although patients with advanced disease show reduced survival, there is no single pathological or molecular feature that identifies aggressive, early‐stage tumours. We retrospectively analysed 282 OSCC patients for disease mortality, related to clinical, pathological, and molecular features based on our previous functional studies [EGFR, αvβ6 integrin, smooth muscle actin (SMA), p53, p16, EP4]. We found that the strongest independent risk factor of early OSCC death was a feature of stroma rather than tumour cells. After adjusting for all factors, high stromal SMA expression, indicating myofibroblast transdifferentiation, produced the highest hazard ratio (3.06, 95% CI 1.65–5.66) and likelihood ratio (3.6; detection rate: false positive rate) of any feature examined, and was strongly associated with mortality, regardless of disease stage. Functional assays showed that OSCC cells can modulate myofibroblast transdifferentiation through αvβ6‐dependent TGF‐β1 activation and that myofibroblasts promote OSCC invasion. Finally, we developed a prognostic model using Cox regression with backward elimination; only SMA expression, metastasis, cohesion, and age were significant. This model was independently validated on a patient subset (detection rate 70%; false positive rate 20%; ROC analysis 77%, p < 0.001). Our study highlights the limited prognostic value of TNM staging and suggests that an SMA‐positive, myofibroblastic stroma is the strongest predictor of OSCC mortality. Whether used independently or as part of a prognostic model, SMA identifies a significant group of patients with aggressive tumours, regardless of disease stage. Copyright

HPV & head and neck cancer: a descriptive update

The incidence of head and neck squamous cell carcinoma (HNSCC) has been gradually increasing over the last three decades. Recent data have now attributed a viral aetiology to a subset of head and neck cancers. Several studies indicate that oral human papillomavirus (HPV) infection is likely to be sexually acquired. The dominance of HPV 16 in HPV+ HNSCC is even greater than that seen in cervical carcinoma of total worldwide cases. Strong evidence suggests that HPV+ status is an important prognostic factor associated with a favourable outcome in head and neck cancers.Approximately 30 to 40% of HNSCC patients with present with early stage I/II disease. These patients are treated with curative intent using single modality treatments either radiation or surgery alone. A non-operative approach is favored for patients in which surgery followed by either radiation alone or radiochemotherapy may lead to severe functional impairment. Cetuximab, a humanized mouse anti-EGFR IgG1 monoclonal antibody, improved locoregional control and overall survival in combination with radiotherapy in locally advanced tumours but at the cost of some increased cardiac morbidity and mortality.Finally, the improved prognosis and treatment responses to chemotherapy and radiotherapy by HPV+ tumours may suggest that HPV status detection is required to better plan and individualize patient treatment regimes.

Balloon dilation eustachian tuboplasty: a feasibility study.

Objective: To assess the feasibility and safety of balloon dilation Eustachian tuboplasty (BET) as an option for treatment of patients with Eustachian tube dysfunction. Patients and Interventions: A cadaveric study of 5 temporal human bones was performed. Each bone underwent transnasal balloon dilation Eustachian tuboplasty (BET) with computed tomography and post-dilation histology. The procedure involved the dilation of the cartilaginous and bony portion of the Eustachian tube with a balloon catheter. Results: BET is technically easy to perform. No damage to essential structures, particularly the carotid canal, was found. Conclusion: This newly introduced method seems to be a feasible and safe procedure to dilate the Eustachian tube.

In vitro examination of suspicious oral lesions using optical coherence tomography

We compared findings of optical coherence tomography (OCT) with histopathological results of suspicious oral lesions to assess the feasibility of using OCT to identify malignant tissue. Thirty-four oral lesions from 27 patients had swept-source frequency-domain OCT. Four variables were assessed (changes in keratin, epithelial, and sub-epithelial layers, and identification of the basement membrane) and from this we calculated whether or not there were architectural changes. These data were then compared with histopathological results. Two clinicians, who were unaware of the clinical and histopathological diagnoses, decided whether biopsy was necessary. The basement membrane was recognised in only 15 oral lesions. OCT could identify diseased areas but could not provide a diagnosis or differentiate between lesions. The two clinicians, who recommended biopsy agreed in all cases. This pilot study confirms the feasibility of using OCT to identify architectural changes in malignant tissues.

Experience versus complication rate in third molar surgery

ObjectivesThe records of 1087 patients who underwent surgical removal of third molar teeth were prospectively examined to analyse the possible relationship between postoperative complications and the surgeons experience parameter.Method and materialsSeven surgeons (three specialists in surgical dentistry [specialists SD] and four oral and maxillofacial Senior House Officers [OMFS residents]) carried out the surgical procedures. For each patient, several variables were recorded including age, gender, radiographic position of extracted teeth, treating surgeon, duration of surgery and postoperative complications.ResultsAnalysis of the data revealed some differences in the incidence of complications produced by the specialists SD and OMFS residents. The main statistically relevant differences were increase the incidences of trismus, nerve paraesthesia, alveolar osteitis and infection in the resident-treated group, while the specialist-treated group showed higher rates of post-operative bleeding.ConclusionThe higher rate of postoperative complications in the resident-treated group suggests that at least some of the complications might be related to surgical experience.Further work needs to compare specialists of training programmes with different years of experience, using large cross – sectional studies.

The Surgical Palliation of Advanced Head and Neck Cancer using Photodynamic Therapy

End-stage head and neck cancer is a difficult disease to manage. The only curative treatment option remains surgery, but this is frequently not feasible. Often, however, significant palliation can be achieved with minimally invasive surgically directed treatments, such as photodynamic therapy. To avoid the morbidity of treating non-cancer areas, photodynamic therapy can now be very accurately directed by radiological imaging along pre-planned grids to document and optimise laser-guided photo-activation of the chemo-sensitiser. Rapid local tumour control often results, enabling the patient to benefit from both a higher quality and length of life.

Photodynamic therapy outcome for oral dysplasia

Photodynamic therapy (PDT) is a minimally invasive surgical intervention used in the management of tissue disorders. It can be applied before, or after, any of the conventional modalities, without compromising these treatments or being compromised itself.

Photodynamic therapy outcome for T1/T2 N0 oral squamous cell carcinoma

This new prospective clinical study assessed the oncological outcomes following surface illumination mTHPC‐photodynamic therapy of T1/T2 N0 oral squamous cell carcinoma (OSCC) patients.

The effect of tobacco and alcohol and their reduction/cessation on mortality in oral cancer patients: short communication

BackgroundThe use of tobacco is known to increase the incidence of developing oral cancer by 6 times, while the additive effect of drinking alcohol further increases the risk leading to higher rate of morbidity and mortality. In this short communication, we prospectively assessed the effect of tobacco smoking and alcohol drinking in oral cancer patients on the overall mortality from the disease, as well as the effect of smoking and drinking reduction/cessation at time of diagnosis on mortality in the same group.Materials and methodsA cohort, involved 67 male patients who were diagnosed with oral squamous cell carcinoma, was included in this study. The smoking and drinking habits of this group were recorded, in addition to reduction/cessation after diagnosis with the disease. Comparisons were made to disease mortality at 3 and 5 years.ResultsFollow-up resulted in a 3-year survival of 46.8% and a 5-year survival of 40.4%. Reduction of tobacco smoking and smoking cessation led to a significant reduction in mortality at 3 (P < 0.001) and 5 (P < 0.001) years. Reduction in drinking alcohol and drinking cessation led to a significant reduction in mortality at 3 (P < 0.001) and 5 (P < 0.001) years.ConclusionChronic smoking and drinking does have an adverse effect on patients with oral cancer leading to increased mortality from cancer-related causes. Reduction/cessation of these habits tends to significantly reduce mortality in this group of patients. Smoking and drinking cessation counseling should be provided to all newly diagnosed oral cancer patients.

Dermatofibrosarcoma protuberans with fibrosarcomatous transformation of the head and neck

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous neoplasm associated with a high cure rate. We present a case of aggressive DFSP with fibrosarcomatous areas in the head and neck. A 28-year-old Mediterranean female presented with a 45-day history of rapidly growing cutaneous lesion of the face. Surgical biopsy confirmed the diagnosis of DFSP. Subsequently, the patient underwent wide local surgical resection, followed by reconstruction. Histopathology report revealed fibrosarcomatous transformation and the patient underwent adjuvant radiotherapy. The patient continues to be disease free at the 35-month follow-up.Although DFSP behave as non-aggressive malignancy, surgery with complete removal of the affected area is the intervention of choice. Moreover, adjuvant treatment and follow-up of the patient is essential in order to prevent recurrence.