Cancer of the gingiva

Detection of human papillomavirus infection in oral cancers reported at dental facility: assessing the utility of FFPE tissues

Incidence of human papillomavirus (HPV)-associated oral cancers is on the rise. However, epidemiological data of this subset of cancers are limited. Dental hospital poses a unique advantage in detection of HPV-positive oral malignancies. We assessed the utility of formalin-fixed paraffin-embedded (FFPE) tissues, which are readily available, for evaluation of high-risk HPV infection in oral cancer. For protocol standardization, we used 20 prospectively collected paired FFPE and fresh tissues of histopathologically confirmed oral cancer cases reported in Oral Medicine department of a dental hospital for comparative study. Only short PCRs (~ 200 bp) of DNA isolated using a modified xylene-free method displayed a concordant HPV result. For HPV analysis, we used additional 30 retrospectively collected FFPE tissues. DNA isolated from these specimens showed an overall 23.4% (11/47) HPV positivity with detection of HPV18. Comparison of HPV positivity from dental hospital FFPE specimens with overall HPV positivity of freshly collected oral cancer specimens (n = 55) from three cancer care hospitals of the same region showed notable difference (12.7%; 7/55). Further, cancer hospital specimens showed HPV16 positivity and displayed a characteristic difference in reported sub-sites and patient spectrum. Overall, using a xylene-free FFPE DNA isolation method clubbed with short amplicon PCR, we showed detection of HPV-positive oral cancer in dental hospitals.

Squamous Cell Carcinoma of the Gingiva

A 77-year-old woman presented with a 2-year history of denture sores at the left mandibular gingiva. She had no smoking history or alcohol use. Intraoral examination showed a cauliflower-like, 28 × 20 mm mass on the left mandibular gingiva without induration. The edentulous ridge was extensively resorbed. Extraoral examination showed no numbness of lower lip and cervical lymphadenopathy. Computed tomography (CT) showed superficial cortical bone erosion beneath the mass and proximity to the inferior alveolar canal. 18 F-fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) showed increased uptake in the left mandibular region and left submandibular lymph nodes. An incisional biopsy was performed, and she was diagnosed with squamous cell carcinoma (SCC)(cT2N1M0, stage 2). She underwent segmental mandibulectomy, selective neck dissection, and immediate reconstruction under general anesthesia. At the 2 years follow-up, she remained free of disease.

Prognostic Exploration of All-Cause Death in Gingival Squamous Cell Carcinoma: A Retrospective Analysis of 2076 Patients

Background

We aimed to establish a prognostic model for gingival squamous cell carcinoma (GSCC) that was superior to traditional AJCC staging and to perform a comprehensive comparison of the newly established nomogram with the AJCC staging system.

Methods

We extracted 2,076 patients with gingival squamous cell carcinoma who had been entered into the SEER (Surveillance, Epidemiology, and End Results) database between 2004 and 2015, and randomly divided 70% of them into the training cohort and the other 30% into the validation cohort. Cox regression analysis was performed in combination with clinical experience and age, race, sex, marital status, tumor location, histological subtype, tumor grade, AJCC stage, chemotherapy status, radiotherapy status, and surgery status as possible prognostic factors. We evaluated and compared the two cohorts using the consistency index (C-index), area under the receiver operating characteristic curves, calibration curves, discriminant improvement index, and decision-curve analysis.

Results

The Cox retrospective analysis showed that age, AJCC stage, tumor grade, histological subtype, radiotherapy status, and surgery status were significant factors to include in the new model of gingival squamous cell carcinoma. The other indicators were also better for the new model than for the AJCC staging system.

Conclusion

We have developed and validated a nomogram for performing reliable gingival squamous cell carcinoma prognoses. The prognostic value of the nomogram is higher than that of the AJCC staging system. We expect that the inclusion of more-comprehensive and authoritative data (i.e., not just limited to residents of the United States) would also allow the construction of reliable nomograms for other populations.

Challenging management of gingival squamous cell carcinoma: a 10 years single-center retrospective study on Northern-Italian patients

Background

Aim of this study was to describe the outcome of patients with gingival squamous cell carcinoma (GSCC), and to recognize aspects affecting clinical course and to consider survival rate.

Material and Methods

The case records of patients, over a 10-year period, were retrospectively examined. Differences in distribution of the potential risk factors by prognosis were investigated through non-parametrical tests (Wilcoxon Rank-Sum and Fisher’s Exact). Survival curves for age, therapy and stage were built by the Kaplan-Meier method and compared with Log-Rank test.

Results

79 patients were analysed. Significant increase in mortality for patients older than 77 and for those with advanced stages was found. Cumulative survival rate 5 years after the diagnosis was 43%, while at 10 years was of 11%.

Conclusions

With a statistical relationship between age and tumour stage with survival rates, and 70% of GSCC cases identified as stage IV, early GSCC diagnosis remains challenging.

Key words:Gingival cancer, clinical appearance, treatment, retrospective study.

Alternative Polyadenylation Modification Patterns Reveal Essential Posttranscription Regulatory Mechanisms of Tumorigenesis in Multiple Tumor Types

Among various risk factors for the initiation and progression of cancer, alternative polyadenylation (APA) is a remarkable endogenous contributor that directly triggers the malignant phenotype of cancer cells. APA affects biological processes at a transcriptional level in various ways. As such, APA can be involved in tumorigenesis through gene expression, protein subcellular localization, or transcription splicing pattern. The APA sites and status of different cancer types may have diverse modification patterns and regulatory mechanisms on transcripts. Potential APA sites were screened by applying several machine learning algorithms on a TCGA-APA dataset. First, a powerful feature selection method, minimum redundancy maximum relevancy, was applied on the dataset, resulting in a feature list. Then, the feature list was fed into the incremental feature selection, which incorporated the support vector machine as the classification algorithm, to extract key APA features and build a classifier. The classifier can classify cancer patients into cancer types with perfect performance. The key APA-modified genes had a potential prognosis ability because of their significant power in the survival analysis of TCGA pan-cancer data.

Multiple gingival metastasis of renal cell carcinoma: a case report

Introduction: Oral metastases are rare and represent only 1% of malignant diseases of the oral cavity, but they are often associated with poor prognosis. The primary tumor is recognizable in most cases; however, in 27.6% of cases, metastasis is the first clinical manifestation. Observation: An 82-year-old consulted for the recent appearance of a 1-cm-wide gingival tumor on 46. Since this patient had metastatic clear cell renal cell carcinoma, oral metastasis was confirmed by histopathology. In the following weeks, other oral metastases appeared. Palliative radiotherapy was the chosen treatment option, but the patient died before he could benefit from it. Discussion: Multiple oral metastases are rare, and metastasis of renal origin is not the most frequently encountered. The metastatic dissemination pathway described is hematogenous or lymphatic. Diagnosis is often easy if the primary tumor is already identified, but is a challenge if it is not, because the lesion often has a nonspecific appearance. Different surgical, radiotherapeutic, and medical therapeutic options exist, but are often palliative. A new immunotherapy route is under development and looks promising in the treatment of renal cell carcinoma. Conclusions: Oral metastasis often has poor prognosis, and management of the lesion is problematic. However, current research suggests a therapeutic and prognostic improvement.

Guidelines for the Surgical Management of Oral Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to provide guidance on the implementation of a surgical treatment of oral cancer. MEDLINE databases were searched for articles on subjects related to “surgical management of oral cancer” published in English. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. The quality of evidence was rated with use RoBANS (Risk of Bias Assessment Tool for Nonrandomized Studies) and AMSTAR (A Measurement Tool to Assess the Methodological Quality of Systematic Reviews). Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. Additional directives are provided as expert opinions and Delphi questionnaire when insufficient evidence existed. The Committee developed 68 evidence-based recommendations in 34 categories intended to assist clinicians and patients and counselors, and health policy-makers. Proper surgical treatment selection for oral cancer, which is directed by patient- and subsite-specific factors, remains the greatest predictor of successful treatment outcomes. These guidelines are intended for use in conjunction with the individual patient’s treatment goals.

Clinical analysis of second primary gingival squamous cell carcinoma after radiotherapy

INTRODUCTION

Clinically, we have observed that some oral cancer patients have a history of radiotherapy for head and neck cancer; we have named this condition radiotherapy-associated cancer (RAC). Gingival cancer, which is usually juxtaposed with other oral cancer subtypes, is seldom reported individually, and there are few reports on the association between the incidence of oral cancer and history of radiation therapy. Therefore, this study aimed to elucidate the clinicopathological features and prognosis of second primary gingival squamous cell carcinoma after head and neck radiotherapy.

MATERIALS AND METHODS

The data collected included 450 patients diagnosed with gingival squamous cell carcinoma from 1964 to 2012 at Sun Yat-sen University Cancer, among whom 52 patients had a history of radiotherapy for head and neck cancer. We retrospectively analysed the differences in the clinicopathological characteristics and prognosis between sporadic gingival squamous cell carcinoma and radiation-associated gingival carcinoma, with an emphasis on gingival carcinoma.

RESULTS

Sporadic gingival squamous cell carcinoma is less likely to have more advanced T stage, and the second primary tumour is more likely to be located in the molar area of the maxillary gingiva than in the mandibular gingiva (75.6% vs 24.4%, P < 0.05). The 5-year overall survival of patients with second primary gingival carcinoma was influenced by age distribution, T classification, N classification, clinical TNM stage, histological grade and radiation history in head and neck. Mandibular gingival carcinoma was more likely to have an increased neck lymph node metastasis than maxillary gingival carcinoma (P = 0.001), but there was no significant difference in 5-year overall survival between these two groups (P = 0.828). The main therapy for gingiva carcinoma is surgery or comprehensive treatment based on surgery.

CONCLUSIONS

Second primary gingival squamous cell carcinoma after radiotherapy demonstrated particular clinicopathologic features, such as prominent sites and TNM stage; and there was statistically significant difference in 5-year overall survival and prognosis between second primary gingival carcinoma after radiotherapy and sporadic gingival carcinoma.

Cervical metastasis of gingival carcinoma misdiagnosed as branchiogenic carcinoma, a rare entity - report of a case and review of literature

BACKGROUND

A cervical cystic mass is associated with a number of pathologies that present with similar symptoms. These conditions are difficult to differentiate using fine-needle aspiration (FNA), ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI). Another dilemma in the differential diagnosis of cervical cystic masses is due to the controversies associated with the existence of branchiogenic carcinoma (BC). BC is an extremely rare disease that must be differentiated from other conditions presenting with cervical cystic masses, especially cystic metastasis from occult primary lesions.

CASE PRESENTATION

We present a case report of a right cervical cystic metastasis from a significantly small squamous cell carcinoma primary gingival lesion misdiagnosed as BC by histopathology. A 62-year-old female presented with a painless progressively enlarging cervical mass at the anterior edge of the sternocleidomastoid muscle in the right submandibular region. Preoperative MRI and US revealed a well-defined cystic round mass. Postoperative histological examination indicated BC. Positron emission tomography/computed tomography (PET/CT) revealed high 18F-FDG (18F 2-fluoro-2-deoxy-D-glucose) uptake in surgical regions with a SUV (standard uptake value) max 4.0 and ipsilateral nasopharynx with a SUVmax 4.4, without any distant metastasis. Pathologic results revealed nasopharyngeal lymphadenosis. Considering the low incidence of BC and the limitation of diagnosis in one institution, the patient was referred to another hospital. Physical examination detected a significantly small neoplasm (~3 mm diameter) in the right lower gingiva. Histopathological examination of the neoplasm revealed a well-differentiated squamous cell carcinoma. Surgery, including a partial mandibulectomy and modified neck dissection (neck level I-V and submental lymph nodes) were undertaken. Postoperative histopathological results revealed a well-differentiated squamous cell carcinoma of right lower gingiva and two metastatic lymph nodes in the 18 lymph nodes of level II. A month later, recurrence occurred in the right cervical level II. The patient was placed on postoperative concurrent chemo-radiotherapy and supportive care. The patient suffered from cachexia and survived for only six months after surgery.

CONCLUSIONS

In cases of cervical cystic masses that appear after the age of 40, clinicians should bear in mind that occult primary lesions should be excluded and examination of the gingiva should be undertaken. PET/CT has a limited role in identifying small occult primary lesions and a comprehensive physical examination must be carefully performed.

Epulis-Like Presentation of Gingival Renal Cancer Metastasis

Mouth metastatic cancers are very rare and they usually represent the evidence of a widespread disease. Common primary tumors are lung carcinoma in men and breast carcinoma in women, followed by kidney cancer. In the oral soft tissues, the gingiva is the most common site, suggesting a possible role of inflammation in the attraction of circulating tumor cells. Oral metastasis has a serious prognosis. In this work, we describe the case of a 58-year-old man affected by renal cancer, who was brought to our attention for the appearance of a gingival swelling. Initially, the lesion was excised through a provisional clinical diagnosis of epulis. Subsequently, anatomopathological analysis showed a metastasis compatible with clear-cell carcinoma and specifically its renal origin was confirmed by immunohistochemical techniques.