Increased expression of cyclooxygenase-2 and Ki-67 are associated with malignant transformation of pleomorphic adenoma

Three-Dimensional Printing of an Apigenin-Loaded Mucoadhesive Film for Tailored Therapy to Oral Leukoplakia and the Chemopreventive Effect on a Rat Model of Oral Carcinogenesis

Oral leukoplakia, which presents as white lesions in the oral cavity, including on the tongue, is precancerous in nature. Conservative treatment is preferable, since surgical removal can markedly reduce the patient’s quality of life. In the present study, we focused on the flavonoid apigenin as a potential compound for preventing carcinogenesis, and an apigenin-loaded mucoadhesive oral film was prepared using a three-dimensional (3D) bioprinter (semi-solid extrusion-type 3D printer). Apigenin-loaded printer inks are composed of pharmaceutical excipients (HPMC, CARBOPOL, and Poloxamer), water, and ethanol to dissolve apigenin, and the appropriate viscosity of printer ink after adjusting the ratios allowed for the successful 3D printing of the film. After drying the 3D-printed object, the resulting film was characterized. The chemopreventive effect of the apigenin-loaded film was evaluated using an experimental rat model that had been exposed to 4-nitroquinoline 1-oxide (4NQO) to induce oral carcinogenesis. Treatment with the apigenin-loaded film showed a remarkable chemopreventive effect based on an analysis of the specimen by immunohistostaining. These results suggest that the apigenin-loaded mucoadhesive film may help prevent carcinogenesis. This successful preparation of apigenin-loaded films by a 3D printer provides useful information for automatically fabricating other tailored films (with individual doses and shapes) for patients with oral leukoplakia in a future clinical setting.

Proliferation in pleomorphic adenoma: Lights and shadow on this parameter, in a neoplasm showing unpredictable behavior-An immunohistochemical study and review of the literature

BACKGROUND

Pleomorphic adenoma accounts for the majority of benign tumors of the salivary gland. It is also called mixed tumor because it is composed by ductal epithelial and myoepithelial cells, variably intermixed within a chondromyxoid stroma. The recurrence rate is around 3.4% and 6.3%, respectively at 5 and 10 years and, to date, there are no valuable predictive factors. Aim of our study was to assess the role of Ki67 proliferative index in our cases and through meta-analysis.

METHODS

Immunohistochemistry with Ki67 antibody was performed on 28 cases. A manual count of the signal was performed, to establish the proliferative activity. Statistical tests were applied to assess the correlation between the score and clinico-pathologic parameters. Further data were extrapolated from studies published on Pubmed, Cochrane and Web of Science database.

RESULTS

Higher values of Ki67 were found among cases with larger size (p value = 0.0061) and showing greater cellularity (p value=0.0004). 19 papers were selected from the bibliographic search, concerning a total of 1187 patients affected by pleomorphic adenoma. In most of them, a higher Ki67 was detected among relapsing forms but results were controversial. In each study, several count methods were applied.

CONCLUSION

The role of Ki67 in pleomorphic adenoma of the salivary glands remains unclear. The lack of homogeneity of the data makes it very difficult to standardize them in order to draw a conclusion. It would therefore be desirable to carry out a comparison study of the various possible methods of Ki67 counting.

Carcinoma ex pleomorphic adenoma: a case report and review of literature

Background

Carcinoma ex pleomorphic adenoma (CA-ex-PA) is extremely unusual in minor salivary glands of oral cavity. CAex-PA is a carcinomatous change as a primary or as a recurrence of pleomorphic adenoma.

Objective

Due to resemblance of clinical symptoms of Ca ex PA and benign pleomorphic adenoma, it is mandatory for surgeons to keep high degree of clinical alertness, considering the peculiarity of this tumor.

Case Report

54-year-old male presented with swelling on left side in the pre-auricular region from the middle of zygomatic arch to mastoid process and from tragus of the ear up to angle of mandible. Fine needle aspiration cytology revealed a mixture of benign and malignant components. Total left parotidectomy with left radical neck dissection followed by reconstruction with cervicodeltopectoral flap was performed. Combination of chemotherapy and radiotherapy were given to patient. Histologic examination and pre-operative fine needle aspiration cytology confirmed the diagnosis of Carcinoma ex pleomorphic adenoma (CA-ex-PA). Two-year follow-up of patient showed no recurrence of the lesion.

Conclusion

Due to the similarity in the clinical symptoms of CA-ex-PA and benign pleomorphic adenoma, it is vital that clinicians maintain a high degree of clinical vigilance, considering the oddity of this malignancy.

Anlotinib is effective in the treatment of advanced carcinoma ex pleomorphic adenoma of the submandibular gland

Background: Carcinoma ex pleomorphic adenoma (CXPA), a very rare malignancy found mostly in the major salivary glands, has no established standardized treatment.

Case presentation: This report describes a 67-year-old male with advanced CXPA who was effectively treated by anlotinib. Pleomorphic adenoma of the submandibular gland was first diagnosed in 1976 after a surgical resection of a mass underneath the jaw. The patient underwent re-excision 3 years later due to a recurrent pleomorphic adenoma. CXPA was first diagnosed in 2016 after a surgical removal of the left submandibular mass. A lung nodule was found on a chest CT scan in January 2018. Following a CT-guided lung biopsy that demonstrated findings consistent with pulmonary metastasis, the patient underwent local therapy (microwave ablation and radioactive seed implantation) but suffered a recurrence of disease approximately 6 months later. Anlotinib was administered orally at a dose of 12 mg daily on a 2 weeks on/1 week off schedule. A partial response was observed after two cycles of treatment. The disease remains in continued partial response after completion of his sixth cycle.

Conclusion: This is the first report for anlotinib in treating CXPA. Further pre-clinical and clinical studies are needed to validate the efficacy and safety of anlotinib in the treatment of CXPA.

Proliferative Index in Invasive Tumor Front of Oral Squamous Cell Carcinoma: A Potential Prognostic Indicator

AIM

The aim of the study was to evaluate the proliferative index (PI) at their invasive front of oral cancer and their association with Bryne's grades of oral squamous cell carcinoma (OSCC) and compare the PI with lymph node metastasis, site of involvement, and habits.

MATERIALS AND METHODS

The Ki-67 antigen expression was immunohistochemically evaluated in a total of 102 cases that included the histopathologically diagnosed archival specimens of OSCCs. They were subdivided by Bryne's histopathological grading into grade I (40 cases), grade II (32 cases), and grade III (30 cases). The nucleus with brown stain was considered positive. Cells were counted under 400× magnification. The proliferative activity thus determined was then expressed as a percentage of Ki-67 labeling index (Ki-67 LI) positive cells.

RESULTS

A stepwise increase in the mean Ki-67 LI was found from grade I to III squamous cell carcinoma, thus correlating with the histological grading. In addition, there was a higher PI seen in cases associated with metastatic lymph node, which concords with the higher biologic aggressiveness and poor prognosis of the lesion.

CONCLUSION

The present study shows a definitive correlation of Ki-67 antigen with the Bryne's histological grading, all the parameters of Bryne's grading for OSCC and lymph node status of the patient proving its association as an effective tool to grade the tumors and finally read the prognosis of the tumor.

CLINICAL SIGNIFICANCE

Cell proliferation is regarded as one of the most important biologic mechanisms in oncogenesis. The role of cell proliferation in tumor progression has been inferred in studies concerned with human cancer by comparing the PI of normal tissue, preneoplastic and neoplastic lesions. The Ki-67 antigen-labeled cells can prove to be an effective aid to grade the tumors. It might be possible to standardize and objectify tumor grading among pathology laboratories.

Carcinoma ex pleomorphic adenoma: case report and options for systemic therapy

The most common benign salivary tumour is a pleomorphic adenoma. Transformation to malignancy, carcinoma ex pleomorphic adenoma (cxpa), occurs in 6% of cases. Management focuses on surgical resection and radiotherapy; however, rare cases require systemic management. We present the case of a 60-year-old woman with a cxpa of the left parotid gland who required systemic therapy for locally recurrent disease. Treatment options were guided by the literature concerning malignant salivary gland tumour and by whole-genome and transcriptome sequencing of the tumour. The patient received multiple systemic agents during the course of her disease, with cyclophosphamide-doxorubicin-cisplatin providing the best control (partial response). Genomeand transcriptome-directed therapy, including sorafenib and vismodegib, were utilized with limited clinical benefit. Malignant transformation in cxpa is a complex process, and therapy directed at a single tumour pathway might not be sufficient to control disease.

Cellular Proliferation Index between Carcinoma Ex-Pleomorphic Adenoma and Pleomorphic Adenoma

<p>Carcinoma ex pleomorphic adenoma (CXPA) has been considered an interesting model of carcinogenesis, presenting various histological subtypes and invasiveness phase. The objective was to determine the proliferative index of CXPA and comparing to pleomorphic adenoma (PA). Thirty six cases of CXPA (36 PA) and 22 areas of PA in CXPA (residual PA) were studied by Ki-67 expression. All CXPA cases were classified according to invasiveness phase (intracapsular, minimally and frankly invasive) and histopathological subtypes. Data was statistically analyzed by Wilcoxon, Mann-Whitney and Kruskal-Wallis tests. CXPA included 5 intracapsular, 9 minimally invasive and 22 frankly invasive cases. Fifteen cases corresponded to salivary duct carcinoma, 7 to adenocarcinoma NOS, 7 myoepithelial, 5 epithelial-myoepithelial, one case of squamous cell and one case of sarcomatoid carcinoma. The Ki-67 index of PA and residual PA were significantly lower than CXPA. Intracapsular and minimally invasive showed smaller proliferative index than frankly invasive. Considering the subtypes of CXPA, there was not a statistic difference among them. Ki-67 is a useful marker in the differential diagnosis of PA and CXPA, even when in the early invasive phase.</p>

Sinonasal tract and nasopharyngeal adenoid cystic carcinoma: a clinicopathologic and immunophenotypic study of 86 cases

Primary sinonasal tract and nasopharyngeal adenoid cystic carcinomas (STACC) are uncommon tumors that are frequently misclassified, resulting in inappropriate clinical management. Eighty-six cases of STACC included 45 females and 41 males, aged 12-91 years (mean 54.4 years). Patients presented most frequently with obstructive symptoms (n = 54), followed by epistaxis (n = 23), auditory symptoms (n = 12), nerve symptoms (n = 11), nasal discharge (n = 11), and/or visual symptoms (n = 10), present for a mean of 18.2 months. The tumors involved the nasal cavity alone (n = 25), nasopharynx alone (n = 13), maxillary sinus alone (n = 4), or a combination of the nasal cavity and paranasal sinuses (n = 44), with a mean size of 3.7 cm. Patients presented equally between low and high stage disease: stage I and II (n = 42) or stage III and IV (n = 44) disease. Histologically, the tumors were invasive (bone: n = 66; neural: n = 47; lymphovascular: n = 33), composed of a variety of growth patterns, including cribriform (n = 33), tubular (n = 16), and solid (n = 9), although frequently a combination of these patterns was seen within a single tumor. Pleomorphism was mild with an intermediate N:C ratio in cells containing hyperchromatic nuclei. Reduplicated basement membrane and glycosaminoglycan material was commonly seen. Necrosis (n = 16) and atypical mitotic figures (n = 11) were infrequently present. Pleomorphic adenoma was present in 9 cases; de-differentiation was seen in two patients. Immunohistochemical studies showed positive reactions for pan-cytokeratin, CK7, CK5/6, CAM5.2, and EMA, with myoepithelial reactivity with SMA, p63, calponin, S100 protein and SMMHC. CD117, CEA, GFAP and p16 were variably present. CK20 and HR HPV were negative. STACC needs to be considered in the differential diagnosis of most sinonasal malignancies, particularly poorly differentiated carcinoma, olfactory neuroblastoma and pleomorphic adenoma. Surgery (n = 82), often accompanied by radiation therapy (n = 36), was generally employed. A majority of patients developed a recurrence (n = 52) 2-144 months after initial presentation. Overall mean follow-up was 19.4 years (range 0.4-37.5 years): 46 patients died with disease (mean 6.4 years); 5 were alive with disease (mean 5.4 years), and 35 patients were either alive or had died of unrelated causes (mean 16.3 years). ACC of the SNT is uncommon. Recurrences are common. The following parameters, when present, suggest an increased incidence of either recurrence or dying with disease: mixed site of involvement, high stage disease (stage IV), skull base involvement, tumor recurrence, a solid histology, perineural invasion, bone invasion, and lymphovascular invasion.

Sinonasal tract adenoid cystic carcinoma ex-pleomorphic adenoma: a clinicopathologic and immunophenotypic study of 9 cases combined with a comprehensive review of the literature

Primary sinonasal tract carcinoma ex-pleomorphic adenoma (CEPA) is very uncommon, with adenoid cystic carcinoma (ACC) CEPA exceptional. These tumors are often misclassified. This is a retrospective study. Nine cases of ACC CEPA included 7 females and 2 males, aged 39-64 years (mean, 51.1 years). Patients presented most frequently with obstructive symptoms (n = 5), epistaxis (n = 3), nerve changes or pain (n = 3), present for a mean of 25 months (men: 9.5 versus women: 29.4 months; p = 0.264). The tumors involved the nasal cavity alone (n = 5), nasopharynx (n = 2), or a combination of locations (n = 2) with a mean size of 2.9 cm (females: 3.3; males: 1.7; p = 0.064). Most patients presented at a low clinical stage (n = 7, stage I), with one patient each in stage II and IV, respectively. Histologically, the tumors showed foci of PA associated with areas of ACC. Tumors showed invasion (lymph-vascular: n = 4; perineural: n = 6; bone: n = 6). The neoplastic cells were arranged in tubules, cribriform and solid patterns, with peg-shaped cells arranged around reduplicated basement membrane and glycosaminoglycan material. Mitoses ranged from 0 to 33, with a mean of 8.7 mitoses/10 HPFs. Necrosis (n = 2) and atypical mitotic figures (n = 1) were seen infrequently. Immunohistochemical studies showed positive reactions for cytokeratin, CK5/6, p63, CK7, EMA, SMA, calponin, S100 protein and CD117, several highlighting luminal versus basal cells components. GFAP, CK20 and MSA were non-reactive. p53 and Ki-67 were reactive to a variable degree. Surgery (n = 8), accompanied by radiation therapy (n = 5) was generally employed. Five patients developed a recurrence, all of whom died with disease (mean, 8.4 years), while 4 patients are either alive (n = 2) or had died (n = 2) without evidence of disease (mean, 15.9 years). In summary, ACC CEPA probably arises from the minor mucoserous glands of the upper aerodigestive tract, usually presenting in patients in middle age with obstructive symptoms in a nasal cavity based tumor. Most patients present with low stage disease (stage I and II), although invasive growth is common. Recurrences develop in about a 55 % of patients, who experience a shorter survival (mean, 8.4 years) than patients without recurrences (mean, 15.9 years). The following parameters, when present, suggest an increased incidence of recurrence or dying with disease: bone invasion, lymph-vascular invasion, and perineural invasion.

Comparison of Ki-67, cyclin E, and p63 in benign and malignant human pleomorphic adenoma

OBJECTIVE

A set of cell proliferation-related molecular markers was used to detect the differences in proliferative activity between benign pleomorphic adenoma (PA) and carcinoma ex pleomorphic adenoma (CXPA).

STUDY DESIGN

Seventy samples comprising 53 PAs, 10 noninvasive and 7 widely invasive (WI) CXPAs were selected. Immunohistochemical staining was used to detect Ki-67, cyclin E, and p63 expression.

RESULTS

The average Ki-67 labeling index of WI CXPAs was higher than that of PAs and the malignant component of noninvasive CXPAs (M-noninvasive CXPA; P < .01). An increased cyclin E-positive staning was observed in M-noninvasive CXPAs and WI CXPAs compared with PAs (P = .006). The p63 expression levels were notably decreased in M-noninvasive CXPAs and WI CXPAs compared with PAs (P = .007).

CONCLUSIONS

The data support that increased or decreased expression of Ki-67, cyclin E, and p63 may indicate the proliferative differences between PA and CXPA.

Increased expression of MDM2 and NM23 are associated with malignant transformation of pleomorphic adenoma

This study was designed to correlate the expression of both MDM2 and NM23 in pleomorphic adenoma (PA) to clinical background, histological features, local recurrence, and metastatic potentiality in this tumor. Expression of MDM2 and NM23 was studied immunohistochemically in 23 cases of PA. Our results demonstrated MDM2 and NM23 overexpression in almost all cases of PA. There was a significant difference of the MDM2 and NM23 mean values between benign PA and both carcinoma-ex PA and metastasizing PA. The results of this study show that the overexpression of NM23 and MDM2 oncoproteins could be used as reliable predictors of malignant progression as well as metastatic potentiality of PA.

Carcinoma ex pleomorphic adenoma: a comprehensive review of clinical, pathological and molecular data

Carcinoma ex pleomorphic adenoma (Ca ex PA) is a carcinoma arising from a primary or recurrent benign pleomorphic adenoma. It often poses a diagnostic challenge to clinicians and pathologists. This study intends to review the literature and highlight the current clinical and molecular perspectives about this entity. The most common clinical presentation of CA ex PA is of a firm mass in the parotid gland. The proportion of adenoma and carcinoma components determines the macroscopic features of this neoplasm. The entity is difficult to diagnose pre-operatively. Pathologic assessment is the gold standard for making the diagnosis. Treatment for Ca ex PA often involves an ablative surgical procedure which may be followed by radiotherapy. Overall, patients with Ca ex PA have a poor prognosis. Accurate diagnosis and aggressive surgical management of patients presenting with Ca ex PA can increase their survival rates. Molecular studies have revealed that the development of Ca ex PA follows a multi-step model of carcinogenesis, with the progressive loss of heterozygosity at chromosomal arms 8q, then 12q and finally 17p. There are specific candidate genes in these regions that are associated with particular stages in the progression of Ca ex PA. In addition, many genes which regulate tumour suppression, cell cycle control, growth factors and cell-cell adhesion play a role in the development and progression of Ca ex PA. It is hopeful that these molecular data can give clues for the diagnosis and management of the disease.

Expression of hMLH1 and hMSH2 proteins in pleomorphic adenoma of minor salivary glands: relationship with clinical and histologic findings

OBJECTIVE

The aim was to examine the relationship between clinicopathological features and immunoexpression of hMLH1 and hMSH2 proteins in pleomorphic adenoma (PA) of minor salivary glands.

STUDY DESIGN

Paraffin-embedded samples of typically benign PA lesions (n = 35) were prepared for histologic and immunohistochemical assessment. Based on the clinicopathologic features, the samples were categorized into low- and high-risk subtypes for their estimated potential for malignant transformation.

RESULTS

Immunohistochemical analysis revealed strong correlations regarding the expression estimation and staining-intensity distribution (SID) scores between the two proteins. Although there was no relationship between marker immunoexpression and SID scores regarding clinical parameters, statistically significant variations for these parameters were evident regarding some histologic criteria or for risk stratification subtypes.

CONCLUSION

The findings of this study could suggest the relationship of a DNA mismatch repair deficiency with high-risk subtypes of PA and the implication of its role in the origin and progression of these subtypes.

Adenoid cystic carcinoma ex pleomorphic adenoma of the parotid gland

There is a considerable variation in the histologic subtype of epithelial malignancies among carcinoma ex pleomorphic adenomas (CXPA) and virtually any known carcinoma entity can develop. To our knowledge, adenoid cystic carcinoma (AdCC) ex PA is quite rare despite the fact that de novo AdCC is the fourth most common salivary gland malignancy. We describe a new case of AdCC ex PA in the parotid gland of a 62 year-old woman. In our patient, there was a short interval of time between parotidectomy and local recurrence and rapid development of distant metastases. Although most of the reported cases are considered low-grade, evidence is presented here that AdCC can take the form of a high-grade malignancy in PA.

Ki67 and salivary cancer

We examined Ki67 expression in salivary malignancies of 75 patients with a follow-up period of up to 20 years. Correlations between enhanced Ki67 and enhanced p53 and TUNEL and heparanase staining levels were significant. Median survival for reduced-stained-tumor patients (< or = 5%) was 163 months, dropping significantly to 39 months (p = 0.0005) for enhanced stained tumors (> 5%); 5 year survival probability was 93% and 33%, respectively, 45% and 16%, respectively, (p = 0.0005) at 20 years. Significant correlation between poor survival and concurrently altered expression rates of Ki67 and p53, p27 Skp2, TUNEL and heparanase in the salivary malignancies indicates a biological role in salivary cancer pathogenesis.