Factors predicting malignant transformation in oral potentially malignant disorders among patients accrued over a 10-year period in South East England

Utility of p53 and p16 immunohistochemistry in the diagnosis of human papillomavirus-associated oral epithelial dysplasia: a retrospective study of 105 patients

AIMS

This study investigated the utility of combined p16 and p53 immunohistochemistry (IHC) for diagnosing high-risk human papillomavirus (HR HPV)-associated oral epithelial dysplasia (OED) and its associated clinical behaviour, including disease recurrence and transformation to malignancy.

METHODS AND RESULTS

The expression of p53 was evaluated in 105 cases of HR HPV-positive oral cavity OED, of which 104 were scored as positive for p16. HPV status was confirmed by reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) for E6 mRNA or RNA in situ hybridization (ISH). Seven cases of p16-positive oral cavity OED with abnormal p53 expression and/or TP53 mutation and negative HPV RNA ISH were excluded. Most cases (93%) demonstrated classic HPV-associated basaloid morphology, and 7% were keratinizing. The most affected sites were the floor of the mouth/ventral tongue (61%), followed by the lateral tongue (18%) and gingiva (13%). p53 IHC showed that 76% of cases demonstrated a null-like / basal-sparing pattern, while 24% demonstrated a mid-epithelial/basal sparing pattern. Ten cases exhibited an invasive or suspicious for microinvasive component on biopsy. Dysplasia recurred in 14 cases, and a single case transformed to squamous cell carcinoma.

CONCLUSION

The combination of p16 positivity and a basal-sparing pattern of p53 is predictive of HR HPV in OED, eliminating the need for further HPV-specific testing. Although HPV OED may co-occur with invasive squamous cell carcinoma on biopsy, the transformation to malignancy is low.

Liquid saliva analysis using optofluidic photonic crystal fiber for detection of oral potentially malignant disorders

Oral potentially malignant disorders (OPMD) serve as early indicators of oral cancer. These conditions require reliable, non-invasive and real-time diagnostic methods for effective detection and screening. Saliva, as an easily accessible and non-invasive biofluid, has emerged as a promising tool to detect OPMD-associated biomarkers. This proof-of-concept study investigated the application of suspended-core optofluidic photonic crystal fibers (PCF) for Raman spectroscopy to distinguish between saliva from healthy controls and OPMD patients. This novel approach provides enhanced Raman signals through prolonged interactions between the excitation light and the saliva sample along the length of the PCF. Raman spectra of liquid saliva samples were collected from eleven participants, including six OPMD patients and five healthy controls. Notable spectral differences were identified at 1123 cm-1, 1251 cm-1, and 1454 cm-1, which correspond to carbohydrates, proteins, and lipids, respectively. In vivo tissue measurements were recorded as a reference for comparative analysis from the same patients. Our findings suggest that PCF-based Raman spectroscopy holds promise as a non-invasive diagnostic platform for oral cancer screening by enabling the monitoring of subtle molecular changes in liquid saliva.

Identification of high-risk oral leukoplakia (OLK) using combined Raman spectroscopic analysis of brush biopsy and saliva samples: A proof of concept study

The gold standard method of diagnosis of oral leukoplakia (OLK) is a tissue biopsy followed by histological examination. Raman spectroscopic studies of cytological brush biopsy and saliva samples have previously been shown to differentiate low (no and mild dysplasia) and high risk (moderate and severe dysplasia) OLKs, discriminant models of cellular samples achieving higher specificity, whereas those based on saliva samples achieved higher sensitivity. The current study combines the spectral data sets of cell and saliva samples in an attempt to improve the overall efficiency of the discriminating models. Raman spectral data from cellular (nucleus and cytoplasm) and saliva samples, collected from patients with OLK (n = 12), was analysed as a concatenated or fused dataset and as data blocks in a multiblock analysis. The concatenated data was subjected to partial least squares-discriminant analysis (PLS-DA) to discriminate high and low grade dysplasia. Finally, multi-block analysis was performed using sequential orthogonalised PLS-DA, by which each set of data blocks was combined sequentially to provide maximum discrimination. For the concatenated dataset of cells and saliva, 87 % sensitivity and 76 % specificity were achieved, while in the case of the multi-block analysis, 97 % sensitivity and 100 % specificity were achieved. It is concluded that multiblock analysis provides maximum sensitivity and specificity using both cell and saliva datasets, compared to fused datasets. This study demonstrates that Raman spectroscopy of minimally invasive brush biopsy and saliva samples could have a role in differentiating high and low-risk OLKs.

Enhancing malignant transformation predictions in oral potentially malignant disorders: A novel machine learning framework using real-world data

This study addresses the challenge of accurately predicting malignant transformation risk in patients with oral potentially malignant disorders (OPMDs). Using data from 1,094 patients across three institutions (2004-2023), the researchers compared traditional statistical methods, including a Cox proportional hazards (Cox-PH) nomogram, with machine learning (ML) algorithms. A novel Self Attention Artificial Neural Network (SANN) model was developed, trained, and validated alongside other ML models including ANN, RF, and DeepSurv. The SANN model outperformed all other approaches, achieving an AUC of 0.9877, with sensitivity, specificity, accuracy, and precision exceeding 0.96. In comparison, the Cox-PH nomogram achieved AUCs of 0.880-0.902. Comprehensive evaluations using Receiver Operating Characteristic, calibration curves, and decision curve analysis demonstrated SANN's superior predictive efficacy, robustness, and generalizability. These findings highlight the potential of customized ML models, particularly SANN, to enhance early identification and management of high-risk OPMD patients, outperforming conventional statistical methods.

Feasibility study of single-image super-resolution scanning system based on deep learning for pathological diagnosis of oral epithelial dysplasia

This study aimed to evaluate the feasibility of applying deep learning combined with a super-resolution scanner for the digital scanning and diagnosis of oral epithelial dysplasia (OED) slides. A model of a super-resolution digital slide scanning system based on deep learning was built and trained using 40 pathological slides of oral epithelial tissue. Two hundred slides with definite OED diagnoses were scanned into digital slides by the DS30R and Nikon scanners, and the scanner parameters were obtained for comparison. Considering that diagnosis under a microscope is the gold standard, the sensitivity and specificity of OED pathological feature recognition by the same pathologist when reading different scanner images were evaluated. Furthermore, the consistency of whole-slide diagnosis results obtained by pathologists using various digital scanning imaging systems was assessed. This was done to evaluate the feasibility of the super-resolution digital slide-scanning system, which is based on deep learning, for the pathological diagnosis of OED. The DS30R scanner processes an entire slide in a single layer within 0.25 min, occupying 0.35GB of storage. In contrast, the Nikon scanner requires 15 min for scanning, utilizing 0.5GB of storage. Following model training, the system enhanced the clarity of imaging pathological sections of oral epithelial tissue. Both the DS30R and Nikon scanners demonstrate high sensitivity and specificity for detecting structural features in OED pathological images; however, DS30R excels at identifying certain cellular features. The agreement in full-section diagnostic conclusions by the same pathologist using different imaging systems was exceptionally high, with kappa values of 0.969 for DS30R-optical microscope and 0.979 for DS30R-Nikon-optical microscope. The performance of the super-resolution microscopic imaging system based on deep learning has improved. It preserves the diagnostic information of the OED and addresses the shortcomings of existing digital scanners, such as slow imaging speed, large data volumes, and challenges in rapid transmission and sharing. This high-quality super-resolution image lays a solid foundation for the future popularization of artificial intelligence (AI) technology and will aid AI in the accurate diagnosis of oral potential malignant diseases.

Oral Leukoplakia Microbiome Predicts the Degree of Dysplasia and is Shaped by Smoking and Tooth Loss

OBJECTIVE

This study aimed to determine if the oral potentially malignant disorder, oral leukoplakia (OLK), exhibited microbiome changes that predict the degree of dysplasia and the risk of malignant progression.

RESULTS

We examined the microbiome in 216 swabs of OLK from 177 patients. Compared to healthy controls (n = 120 swabs from 61 patients), who were less likely to smoke and had better oral health, OLK patients exhibited an increased abundance of Rothia mucilaginosa, Streptococcus parasanguinis and S. salivarius, resembling acetaldehyde generating communities described previously. Compared to the patients' healthy contralateral normal (CLN) mucosa (n = 202), which acts as a matched control for oral health parameters, OLK exhibited increased S. infantis, Leptotrichia spp., Bergeyella spp., Porphyromonas spp. and F. nucleatum. Machine learning with clinical and microbiome data could discriminate high-risk dysplasia (moderate to severe) from low-risk dysplasia (none or mild) (sensitivity 87.4%; specificity 76.5%). Follow-up swabs were recovered from 58 patients, eight of whom progressed to a higher grade of dysplasia or OSCC and these eight patients exhibited a higher abundance of Fusobacterium species at their initial presentation.

CONCLUSIONS

Our study suggests that the OLK microbiome has potential to be an aid to the prediction of dysplasia grade and the risk of malignant transformation.

Recommendations for Research to Develop a Patient-Centered Clinical Follow-Up Protocol for Oral Epithelial Dysplasia

Oral epithelial dysplasia (OED) is the primary histological marker for assessing the progression of oral potentially malignant disorders (OPMDs) to cancer. Despite challenges in grading and low inter-pathologist reproducibility, OED severity remains the key predictor of malignant transformation. However, globally accepted guidelines for OED monitoring are lacking, despite calls for individualized management based on host and lesion characteristics. The proposed research protocol involves acquiring high-quality intraoral images, assessing oral hygiene and periodontal status, eliminating chronic mechanical irritation and Candida infections, and applying adjunctive diagnostic methods like toluidine blue staining, optical evaluation, and brush cytology. Tailored follow-up regimens based on individual risk assessments are emphasized, with frequent monitoring for high-grade dysplasia or patients at higher risk of progression. Therefore, effective OED management should consider the patient's immune status, dietary habits, and oral microbiota, aiming to develop personalized treatment strategies that optimize patient-centered care.

Anti-VEGFR2 neutralising antibody slows the progression of multistep oral carcinogenesis

Angiogenesis plays an important role in cancer growth and metastasis, and it is considered a therapeutic target to control tumour growth following anti-angiogenic therapy. However, it is still unclear when tissues initiate angiogenesis during malignant transformation from premalignant condition and whether this premalignant condition could be a therapeutic target of anti-angiogenic therapy. In this study, we aimed to analyse the onset of angiogenesis by evaluating morphological and functional alterations of microvessels during oral multistep carcinogenesis using a 4-nitroquinoline 1-oxide (4NQO)-induced oral carcinogenesis mouse model. In the study, we initially confirmed that with the use of 4NQO, oral lesions develop in a stepwise manner from normal mucosa through oral epithelial dysplasia (OED) to oral squamous cell carcinoma (OSCC). Evaluation of CD31-immunostained specimens revealed that microvessel density (MVD) increases in a stepwise manner from OEDs. Histological and functional analyses revealed the structural abnormalities and leakage of blood vessels had already taken place in OED. Then we evaluated the expression profiles of Hif1a and Vegfa along with hypoxic status and found that OED exhibited increased Vegfa expression under hypoxic conditions. Finally, we tested the possibility of OEDs as a target of anti-angiogenic therapy and found that anti-VEGFR2 neutralising antibody in OED slowed the disease progression from OED to OSCC. These data indicate that an angiogenic switch occurs at the premalignant stage and morphological, and functional alterations of microvessels already exist in OED. These findings also elucidate the tumour microenvironment, which gradually develops along with carcinogenic processes, and highlight usefulness of the 4NQO-induced carcinogenesis model in the study of epithelial and stromal components, which will support epithelial carcinogenesis. © 2024 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Recurrence in Oral Leukoplakia: A Systematic Review and Meta-analysis

The management of oral leukoplakia (OL) is challenging because of a high risk for recurrence and malignant transformation (MT), and recurrent OL is associated with a higher risk of MT than nonrecurrent OL. The present meta-analysis aimed to examine the association between OL recurrence and surgical techniques used for their management as well as their clinicopathological factors. Electronic searches were conducted in EMBASE, PubMed, Scopus, and Web of Science to retrieve studies reporting OL recurrence after surgery. The pooled proportion of OL recurrence after surgical excision was estimated. Subgroup analyses were conducted based on the surgical technique, data type, grades of epithelial dysplasia, anatomical subsites, clinical type and size of the lesion, surgical margin, and risk habits. Meta-regression analyses were conducted to identify the association between age, sex, and follow-up duration and OL recurrence. The risk of MT based on the recurrence status was also estimated. A network meta-analysis was performed to determine the surgical modality associated with the least OL recurrence. Eighty studies with a total of 7,614 samples and various surgical modalities (laser-based techniques, conventional scalpel surgery, cryosurgery, and photodynamic therapy) were included in the meta-analysis. A pooled proportion of recurrence of 22% was observed. Laser-based surgeries resulted in fewer OL recurrences than other surgical modalities, and the combination of laser excision and vaporization was identified to be the best treatment approach. OL in the retromolar area and multiple sites, nonhomogeneous OL, advanced age, female sex, inadequate surgical margin, retrospective data, and betel quid chewing habit were significantly associated with higher OL recurrence. Recurrent OL showed a 7.39 times higher risk of MT than nonrecurrent OL. These results suggest that the combination of laser excision and vaporization might reduce OL recurrence. Furthermore, OL in older patients, females, and nonhomogeneous OL need close monitoring after any surgical therapy.

Genomic alterations in the stepwise progression from normal mucosa to metastasizing oral squamous cell carcinoma

Introduction

The aim of this study was to investigate the genomic changes that occur in the development from dysplasia, cancer and to regional metastases in patients with oral cavity squamous cell carcinoma (OSCC).

Material and methods

We included OSCC patients with lymph node metastases at diagnosis, treated with primary surgery at Rigshospitalet, University of Copenhagen in the period 2007-2014. The resected tumor specimens were evaluated by a pathologist, who marked areas of morphologically normal tissue and dysplasia surrounding the cancer, two areas from the cancer tissue, and one area within the lymph node metastases. From these areas a punch biopsy was taken, and DNA from each sample was extracted and sequenced using Illumina's TSO500 HT cancer panel.

Results

From 51 OSCC patients, 255 samples were included, comprising a wide variety of genomic alterations. Substantial intratumor heterogeneity was found. The most commonly mutated gene was TP53, mutated in 65% of all samples. Only two patients had no TP53 mutation in any samples. We found that morphologically normal appearing mucosa as well as surrounding dysplasia also contained malignant mutations, supporting the theory of field cancerization. There was a significant lower average tumor mutational burden (TMB) in the lymph node metastases compared to the primary tumors, supporting the theory of clonal selection.

Conclusion

Substantial inter- and intratumor genomic heterogeneity was found. Mutation of TP53 was the most common and was present in all but two patients. Our data strongly supports the theory of clonal selection and the theory of field cancerization.

Oral epithelial dysplasia detection and grading in oral leukoplakia using deep learning

BACKGROUND

The grading of oral epithelial dysplasia is often time-consuming for oral pathologists and the results are poorly reproducible between observers. In this study, we aimed to establish an objective, accurate and useful detection and grading system for oral epithelial dysplasia in the whole-slides of oral leukoplakia.

METHODS

Four convolutional neural networks were compared using the image patches from 56 whole-slide of oral leukoplakia labeled by pathologists as the gold standard. Sequentially, feature detection models were trained, validated and tested with 1,000 image patches using the optimal network. Lastly, a comprehensive system named E-MOD-plus was established by combining feature detection models and a multiclass logistic model.

RESULTS

EfficientNet-B0 was selected as the optimal network to build feature detection models. In the internal dataset of whole-slide images, the prediction accuracy of E-MOD-plus was 81.3% (95% confidence interval: 71.4-90.5%) and the area under the receiver operating characteristic curve was 0.793 (95% confidence interval: 0.650 to 0.925); in the external dataset of 229 tissue microarray images, the prediction accuracy was 86.5% (95% confidence interval: 82.4-90.0%) and the area under the receiver operating characteristic curve was 0.669 (95% confidence interval: 0.496 to 0.843).

CONCLUSIONS

E-MOD-plus was objective and accurate in the detection of pathological features as well as the grading of oral epithelial dysplasia, and had potential to assist pathologists in clinical practice.

Post-radiation lichen planus: a case report and review of the literature

BACKGROUND

Lichen planus is a T-cell mediated inflammatory disorder of the skin and mucus membranes and is a rare complication of external beam radiation.

CASE PRESENTATION

64 year old White male who presented to dermatology with a lesion at the lateral aspect of the right thigh. The lesion was first noted 40 years prior and had grown from 1.5 cm to 6.5 cm in the ensuing years. On examination the lesion was raised, hypopigmented, with pearly borders and central ulceration. Wide excision with lymph node dissection demonstrated invasive squamous cell carcinoma, basaloid type, with negative margins. Patient had radiation therapy of the right inguinal nodes. Patient subsequently noted a "blister" on the right upper thigh, which progressed over time to flat, polygonal, intensely pruritic lesions that covered the right lateral thigh from just distal to the hip to the distal third of the femur (Figs. 1, 2). Skin biopsy was positive for lichen planus. He was started on topical triamcinolone with salutary effects on appearance and pruritus. Fig. 1 Lichen planus, right thigh Fig. 2 Closeup, lichen planus, right thigh, demonstrating polygonal papules CONCLUSION: Once more biopsy-proven cases of post-radiation lichen planus are reported, hopefully the exact mechanism can be elucidated. This may identify risk factors and aid in treatment, with the goal of limiting radiation toxicity and palliation of symptoms that may affect the quality of daily life.

An Evidence-Based Update on the Potential for Malignancy of Oral Lichen Planus and Related Conditions: A Systematic Review and Meta-Analysis

A systematic review and a meta-analysis is presented on published articles on the malignant transformation of oral lichen planus (OLP) and related conditions, which, based on current evidence, updates an earlier systematic review published by our research group that included publications until November 2018. In this updated study (Nov-2023) we searched MEDLINE, Embase, Web of Science, and Scopus. We evaluated the methodological quality of studies (QUIPS tool) and carried out meta-analyses. The inclusion criteria were met by 101 studies (38,083 patients), of which, 20 new primary-level studies (11,512 patients) were published in the last 5 years and were added to our updated study. The pooled malignant transformation ratio was 1.43% (95% CI = 1.09-1.80) for OLP; 1.38% (95% CI = 0.16-3.38) for oral lichenoid lesions; 1.20% (95% CI = 0.00-4.25) for lichenoid reactions; and 5.13% (95% CI = 1.90-9.43) for OLP with dysplasia. No significant differences were found between the OLL or LR groups and the OLP subgroup (p = 0.853 and p = 0.328, respectively), and the malignant transformation was significantly higher for the OLP with dysplasia group in comparison with the OLP group (p = 0.001). The factors that had a significant impact with a higher risk of malignant transformation were the presence of epithelial dysplasia, a higher methodological quality, the consumption of tobacco and alcohol, the location of lesions on the tongue, the presence of atrophic and erosive lesions, and infection by the hepatitis C virus. In conclusion, OLP behaves as an oral potentially malignant disorder (OPMD), whose malignancy ratio is probably underestimated as a consequence essentially of the use of inadequate diagnostic criteria and the low methodological quality of the studies on the subject.

Prevalence and diagnostic significance of p16, p53 expression in lichen planus as a potential premalignant lesion in oral squamous cell carcinoma

Background

Oral squamous cell carcinoma (OSCC) is a prevalent malignancy with significant morbidity and mortality. Identifying potential premalignant lesions is crucial for early detection and effective management. Lichen planus (LP), a chronic inflammatory disorder has been associated with an increased risk of developing OSCC. This study aimed to assess the diagnostic importance of p16 and p53 expression in identifying LP as a potential premalignant lesion for OSCC.

Materials and Methods

A retrospective analysis was conducted on archived tissue samples from patients diagnosed with LP (n = 80) and OSCC (n = 60) between 2017 and 2022. Immunohistochemistry was performed to evaluate p16 and p53 protein expression levels in both LP and OSCC tissues. Clinical data, including patient demographics and lesion characteristics, were collected and correlated with the immunohistochemical findings.

Results and Discussion

The results revealed a significantly higher prevalence of p16 and p53 expression in LP tissues compared to normal oral mucosa (P < 0.001). Notably, p16 expression was observed in 70% of LP cases, while p53 was detected in 55% of LP cases. Furthermore, a significant association was established between p53 expression and the presence of dysplasia within LP lesions (P = 0.003). This indicates the potential of p53 as a predictive biomarker for malignant transformation in LP. The correlation between p16 and p53 expression levels in LP and OSCC tissues suggests a potential mechanistic link between LP and OSCC development.

Conclusion

This study underscores the diagnostic importance of p16 and p53 expression as potential markers for identifying LP as a premalignant lesion in the context of OSCC. The elevated prevalence of these markers in LP tissues suggests a potential role in predicting malignant transformation. The findings contribute to a deeper understanding of the molecular pathways underlying OSCC development from LP and emphasize the need for regular monitoring and early intervention in patients diagnosed with LP. Further prospective studies are warranted to validate these findings and to explore the clinical utility of p16 and p53 as biomarkers for predicting OSCC risk in LP patients.

Is Systemic Immunosuppression a Risk Factor for Oral Cancer? A Systematic Review and Meta-Analysis

Even if the relationship between immunosuppression and increased incidence of systemic cancers is well known, there is less awareness about the risk of developing oral cancer in immunosuppressed patients. The aim of this review was to evaluate the association between immunosuppression and the development of oral cancer. Two authors independently and, in duplicate, conducted a systematic literature review of international journals and electronic databases (MEDLINE via OVID, Scopus, and Web of Science) from their inception to 28 April 2023. The assessment of risk of bias and overall quality of evidence was performed using the Newcastle-Ottawa Scale and GRADE system. A total of 2843 articles was identified, of which 44 met the inclusion criteria and were included in either the qualitative or quantitative analysis. The methodological quality of the included studies was generally high or moderate. The quantitative analysis of the studies revealed that immunosuppression should be considered a risk factor for the development of oral cancer, with a percentage of increased risk ranging from 0.2% to 1% (95% CI: 0.2% to 1.4%). In conclusion, the results suggest that a constant and accurate follow-up should be reserved for all immunosuppressed patients as a crucial strategy to intercept lesions that have an increased potential to evolve into oral cancer.

Rate of Malignant Transformation Differs Based on Diagnostic Criteria for Oral Lichenoid Conditions: A Systematic Review and Meta-Analysis of 24,277 Patients

OBJECTIVES

This systematic review and meta-analysis aims to evaluate the evidence on the malignant potential of oral lichenoid conditions (OLCs) including oral lichen planus (OLP), oral lichenoid lesions (OLL), and lichenoid mucositis dysplasia (LMD). In addition, it aims to compare the rate of malignant transformation (MT) in OLP patients diagnosed according to different diagnostic criteria, and to investigate the possible risk factors for OLP MT into OSCC.

MATERIALS AND METHODS

A standardized search strategy was applied across four databases (PubMed, Embase, Web of Science, and Scopus). Screening, identification and reporting followed the PRISMA framework. Data on MT were calculated as a pooled proportion (PP), subgroup analyses and possible risk factors for MT were pooled as odds ratios (ORs).

RESULTS

Among 54 studies with 24,277 patients, the PP for OLCs MT was 1.07% (95% CI [0.82, 1.32]). The estimated MT rate for OLP, OLL and LMD was 0.94%, 1.95% and 6.31%, respectively. The PP OLP MT rate using the 2003 modified WHO criteria group was lower than that using the non-2003 criteria (0.86%; 95% CI [0.51, 1.22] versus 1.01%; 95% CI [0.67, 1.35]). A higher odds ratio of MT was observed for red OLP lesions (OR = 3.52; 95% CI [2.20, 5.64]), smokers (OR = 1.79; 95% CI [1.02, 3.03]), alcohol consumers (OR = 3.27, 95% CI [1.11, 9.64]) and those infected with HCV (OR = 2.55, 95% CI [1.58, 4.13]), compared to those without these risk factors.

CONCLUSIONS

OLP and OLL carry a low risk of developing OSCC. MT rates differed based on diagnostic criteria. A higher odds ratio of MT was observed among red OLP lesions, smokers, alcohol consumers, and HCV-positive patients. These findings have implications for practice and policies.

Diagnosis of oral potentially malignant disorders: Overview and experience in Oceania

The diagnosis and management of oral potentially malignant disorders (OPMD) should be the same the world over, but there are important nuances in incidence, aetiological factors, and management opportunities that may lead to differences based on ethnogeography. In this review, we update and discuss current international trends in the classification and diagnosis of OPMD with reference to our experience in various regions in Oceania. Oceania includes the islands of Australia, Melanesia (including Papua New Guinea, Fiji, Solomon Islands, Micronesia and Polynesia (including New Zealand, Samoa, Tonga) and hence has diverse populations with very different cultures and a range from well-resourced high-population density cities to remote villages.

[Esophageal Lichen Planus - An Underdiagnosed Disease]

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middleaged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of "new" immunologic diseases of the esophagus.

[Esophageal Lichen Planus - An Underdiagnosed Disease]

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middleaged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of "new" immunologic diseases of the esophagus.

Narrow-band imaging features of oral lichenoid conditions: A multicentre retrospective study

OBJECTIVE

Narrow-band imaging (NBI), which highlights epithelial intrapapillary capillary loops (IPCLs) classified into five patterns (0 toIV) with increasing correlation to malignancy, has demonstrated effectiveness for detection of oral squamous cell carcinoma (OSCC). Lack of standardised procedures limits its use for routine inspection of oral lichenoid lesions including oral lichen planus (OLP), oral lichenoid lesion (OLL) and oral lichenoid reaction (OLR). The aim of this study was to analyse IPCL patterns of such lesions, assessing correlations with histopathological outcomes.

MATERIALS AND METHODS

A multicentre, retrospective study was performed on 84 patients who underwent NBI and subsequent biopsy for suspected OLP/OLL/OLR. Patients were examined with Evis Exera III NBI system. Recorded NBI video endoscopies were evaluated to assess IPCL patterns and correlated with histopathological outcomes.

RESULTS

No significant differences were detected among OLP/OLL/OLR on NBI inspection. All lichenoid lesions were significantly related to low-grade (0-II) IPCL patterns, clearly distinguishable from OSCC, showing pattern IV (p < 0.05).

CONCLUSIONS

NBI cannot discern among OLP/OLL/OLR lesions. Interpretation should be modulated when assessing lichenoid lesions. NBI has potential to discern malignant transformation occurring in lichenoid lesions undergoing long-term follow-up, as IPCL pattern IV may be used as a clinical marker of malignancy arising in chronic inflammatory lesions.

Practice patterns for initial management of oral leukoplakia amongst otolaryngologists and oral and maxillofacial surgeons

OBJECTIVE

Oral leukoplakia is encountered frequently by otolaryngologists and oral and maxillofacial surgeons (OMFS). There are no consensus practice management guidelines for oral leukoplakia, resulting in heterogeneity in practice patterns. Characterization of practice patterns of providers who treat oral leukoplakia will be valuable to establish standards of care and future practice guidelines.

MATERIAL AND METHODS

A survey was designed by the American Head and Neck Society Cancer Prevention Service collecting demographic and practice management data for treating oral leukoplakia. The survey was approved and distributed to members of the American Academy of Otolaryngology-Head and Neck Surgery and American Association of Oral and Maxillofacial Surgeons. Data analysis was performed using chi square and t-test where appropriate.

RESULTS

396 responses were collected: 83 OMFS, 81 head and neck fellowship-trained providers, and 232 otolaryngologists (non-head and neck fellowship-trained). Providers saw a wide volume of oral leukoplakia (23.0% >30 cases/year, 35.1% 11-30 cases/year, 41.2% 10 or less cases/year), with OMFS seeing more cases of oral leukoplakia. Factors most associated with consideration of initial biopsy included physical exam findings (94.4%), erythroplakia (82.3%), and smoking status (81.6%). The majority of respondents saw patients in follow-up within 1 month (24.8%) or within 1-3 months (46.5%).

CONCLUSION

This survey identifies a range of practice patterns in initial management of oral leukoplakia, including indications for biopsy, and time for follow-up. This data provide insight into practice patterns amongst different groups of providers and can potentially lead to consensus guidelines for initial management of oral leukoplakia.

Mildly dysplastic oral lesions with optically-detectable abnormalities share genetic similarities with severely dysplastic lesions

OBJECTIVE

Optical imaging studies of oral premalignant lesions have shown that optical markers, including loss of autofluorescence and altered morphology of epithelial cell nuclei, are predictive of high-grade pathology. While these optical markers are consistently positive in lesions with moderate/severe dysplasia or cancer, they are positive only in a subset of lesions with mild dysplasia. This study compared the gene expression profiles of lesions with mild dysplasia (stratified by optical marker status) to lesions with severe dysplasia and without dysplasia.

MATERIALS AND METHODS

Forty oral lesions imaged in patients undergoing oral surgery were analyzed: nine without dysplasia, nine with severe dysplasia, and 22 with mild dysplasia. Samples were submitted for high throughput gene expression analysis.

RESULTS

The analysis revealed 116 genes differentially expressed among sites without dysplasia and sites with severe dysplasia; 50 were correlated with an optical marker quantifying altered nuclear morphology. Ten of 11 sites with mild dysplasia and positive optical markers (91%) had gene expression similar to sites with severe dysplasia. Nine of 11 sites with mild dysplasia and negative optical markers (82%) had similar gene expression as sites without dysplasia.

CONCLUSION

This study suggests that optical imaging may help identify patients with mild dysplasia who require more intensive clinical follow-up. If validated, this would represent a significant advance in patient care for patients with oral premalignant lesions.

Esophageal lichen planus: Current knowledge, challenges and future perspectives

Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.

Clinical predictors of malignant transformation and recurrence in oral potentially malignant disorders: A systematic review and meta-analysis

OBJECTIVE

We performed a systematic review dedicated to pooling evidence for the associations of clinical features with malignant transformation (MT) and recurrence of 3 oral potentially malignant disorders (OPMDs) (actinic cheilitis [AC], oral leukoplakia [OL], and proliferative verrucous leukoplakia [PVL]).

STUDY DESIGN

We selected studies that included clinical features and risk factors (age, sex, site, size, appearance, alcohol intake, tobacco use, and sun exposure) of OL, PVL, and AC associated with recurrence and/or MT.

RESULTS

Based on the meta-analysis results, non-homogeneous OL appears to have a 4.53 times higher chance of recurrence after treatment. We also found 6.52 higher chances of MT of non-homogeneous OL. Another clinical feature related to higher MT chances is the location (floor of the mouth and tongue has 4.48 higher chances) and the size (OL with >200 mm2 in size has 4.10 higher chances of MT). Regarding habits, nonsmoking patients with OL have a 3.20 higher chance of MT. The only clinical feature related to higher chances of MT in patients with PVL was sex (females have a 2.50 higher chance of MT).

CONCLUSIONS

Our study showed that some clinical features may indicate greater chances of recurrence after treatment and MT of OPMD.

Automated detection of premalignant oral lesions on whole slide images using convolutional neural networks

INTRODUCTION

Oral epithelial dysplasia (OED) is a precursor lesion to oral squamous cell carcinoma, a disease with a reported overall survival rate of 56 percent across all stages. Accurate detection of OED is critical as progression to oral cancer can be impeded with complete excision of premalignant lesions. However, previous research has demonstrated that the task of grading of OED, even when performed by highly trained experts, is subject to high rates of reader variability and misdiagnosis. Thus, our study aims to develop a convolutional neural network (CNN) model that can identify regions suspicious for OED whole-slide pathology images.

METHODS

During model development, we optimized key training hyperparameters including loss function on 112 pathologist annotated cases between the training and validation sets. Then, we compared OED segmentation and classification metrics between two well-established CNN architectures for medical imaging, DeepLabv3+ and UNet++. To further assess generalizability, we assessed case-level performance of a held-out test set of 44 whole-slide images.

RESULTS

DeepLabv3+ outperformed UNet++ in overall accuracy, precision, and segmentation metrics in a 4-fold cross validation study. When applied to the held-out test set, our best performing DeepLabv3+ model achieved an overall accuracy and F1-Score of 93.3 percent and 90.9 percent, respectively.

CONCLUSION

The present study trained and implemented a CNN-based deep learning model for identification and segmentation of oral epithelial dysplasia (OED) with reasonable success. Computer assisted detection was shown to be feasible in detecting premalignant/precancerous oral lesions, laying groundwork for eventual clinical implementation.

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.

Photodynamic Diagnosis Using 5-Aminolevulinic Acid with a Novel Compact System and Chromaticity Analysis for the Detection of Oral Cancer and High-Risk Potentially Malignant Oral Disorders

Detecting early-stage oral cancer and precancerous lesions are critical to improving patient prognosis and quality of life after treatment. Photodynamic diagnosis using 5-aminolevulinic acid enables the detection of malignant lesions. This study aimed to improve the diagnostic accuracy of photodynamic diagnosis using an objective chromaticity analysis of fluorescence emitted from oral lesions. Sixty-seven patients with clinically suspicious oral cavity lesions underwent photodynamic diagnosis after topical application of 5-aminolevulinic acid solution, followed by imaging and histological evaluation of the lesions. Chromaticity red and green values were measured from the fluorescence images on the lesion, and the red-to-green ratio was calculated. The photodynamic diagnosis allowed for the visualization of oral cancer and high-risk dysplasia as red fluorescence. Compared to low-risk dysplasia and benign lesions, oral cancer and high-risk dysplasia areas had a significantly higher red value and red-to-green ratio. After setting the cutoff value, sensitivity and specificity were 83.3–88.7% and 83.3–83.9%, respectively, when discriminating between oral cancer or high-risk dysplasia and low-risk dysplasia or benign lesions. Photodynamic diagnosis combined with chromaticity analysis may be a valuable diagnostic tool for detecting oral lesions, with a high likelihood of malignant transformation.

Clinical Evaluation of the Optical Filter for Autofluorescence Glasses for Oral Cancer Curing Light Exposed (GOCCLES®) in the Management of Potentially Premalignant Disorders: A Retrospective Study

BACKGROUND

Any oral potentially malignant disorders (OPMDs) must be regularly monitored through clinical examination to detect any possible malignant transformation. Conventional intraoral exams, however, can be difficult because these conditions may resemble benign lesions. For this reason, several non-invasive diagnostic technologies have been developed to help the clinician in detecting and distinguishing between cancerous and benign lesions. Epithelial dysplasia can be considered the most important predictor of malignant evolution. Therefore, in this study we aim to evaluate the ability of an optical filter for autofluorescence Glasses for Oral Cancer Curing Light Exposed (GOCCLES®) and of toluidine blue staining in identifying dysplastic areas in patients with OPMDs.

METHODS

In this retrospective study, medical records, photographs and videos of 25 patients with oral lesions were analyzed. Forty-two biopsy samples in 25 patients with OPMDs and at least one suspicious oral mucosa lesion that were evaluated in white light, autofluorescence with optical filter GOCCLES®, toluidine blue staining and then biopsied with histopathological analysis were analyzed.

RESULTS

The sensitivity and specificity for the autofluorescence evaluation with GOCCLES® for identifying dysplasia or carcinoma were 66% and 48%, respectively. The positive and negative predictive values were 34% and 77%, respectively, and the accuracy was 53%. The sensitivity and specificity for toluidine blue staining were 91% and 68%, respectively. The positive and negative predictive values were 55% and 95%, respectively, and the accuracy was 75%.

CONCLUSIONS

The optical filter for autofluorescence (GOCCLES®) and toluidine blue staining are simple, inexpensive, rapid and non-invasive procedures that can assist the clinician in distinguishing OPMDs from healthy mucosa but they are not able to distinguish benign and malignant lesions.

The expression of salivary microRNAs in oral lichen planus: Searching for a prognostic biomarker

Oral lichen planus (OLP) is a premalignant disease with unknown etiology. It has been demonstrated that inflammation and immune activation play a central role in the pathogenesis of OLP. Various cellular and molecular mechanisms are involved in the pathogenesis of OLP. Studies have shown that 2-7% of OLP patients develop oral squamous cell carcinoma (OSCC). As a result, determining the prognosis of the disease will be promising in preventing oral carcinoma. MicroRNAs are involved in the regulation of cytokine expression and cytokines have a central role in the pathogenesis of OLP. As a result, their evaluation in body fluids may be helpful in assessing the disease's status and progression, and facilitating the treatment process. In this regard, much attention has been paid to the saliva of OLP patients as the sampling is cost-effective and non-invasive. Here, we discuss the potential of miRNAs in predicting the disease severity and progression.

Effect of clinical and histologic features on time to malignancy in 224 cases of oral leukoplakia treated by surgery

Objectives

Our main purpose and research question were to analyze and quantify whether there were significant differences in the time to develop cancer among patients with oral leukoplakia (OL), comparing the more susceptible cases to those with the least susceptibility to malignancy.

Materials and methods

We followed 224 cases of OL after surgical or CO₂ laser treatment for a mean time of 6.4 years. A Bayesian mixture cure model based on the Weibull distribution was used to model the relationship between our variables and cancer risk. In this model type, the population is considered a mixture of individuals who are susceptible or non-susceptible to developing cancer. The statistical model estimates the probability of cure (incidence model) and then infers the time to malignancy. The model was adjusted using the R-package INLA using default priors.

Results

Histology type (moderate or severe dysplasia) and tongue location showed hazard ratios (HR) of 3.19 (95% CI [1.05–8.59]) and 4.78 (95% CI [1.6–16.61]), respectively. Both variables increased the risk of malignant transformation, thus identifying a susceptible subpopulation with reduced time required to develop cancer, as with non-homogeneous leukoplakias. The median time for cancer development was 4 years and 5 months, with a minimum of 9 months after the diagnosis of OL and a maximum of 15 years and 2 months.

Conclusions

Susceptible patients with non-homogeneous leukoplakia, dysplasia, or leukoplakia in the tongue develop cancer earlier than those with homogeneous OL and those without dysplasia.

Clinical relevance

The novel contribution of this research is that, until now, the time it took for oral leukoplakias to develop cancer based on whether they were homogeneous or non-homogeneous, and if they have or not epithelial dysplasia, had not been comparatively described and quantified. As a final result, the time to malignant transformation in non-homogeneous and dysplastic leukoplakias is significantly shorter.

Podoplanin Expression Independently and Jointly with Oral Epithelial Dysplasia Grade Acts as a Potential Biomarker of Malignant Transformation in Oral Leukoplakia

Our aim was to evaluate the expression of biomarkers, CD44v6, CD147, EGFR, p53, p63, p73, p16, and podoplanin in oral leukoplakias (OL) and to assess their potential for prediction of malignant transformation (MT). We analyzed the expression of CD44v6, CD147, EGFR, p53, p63, p73, p16, and podoplanin by immunohistochemistry in 52 OL, comprised of 41 low-grade (LG) dysplasia and 11 high-grade (HG) cases. Twelve healthy normal tissues (NT) were also included. Univariate and multivariate analysis were performed to evaluate any association with MT. Variable expression among the studied markers was observed, with a significant increase of high expression from NT to LG and HG cases in CD44v6 (p = 0.002), P53 (p = 0.002), P73 (p = 0.043), and podoplanin (p < 0.001). In multivariate analysis, cases with high podoplanin score showed a significant increased risk of MT (HR of 10.148 (95% CI of 1.503−68.532; p = 0.017). Furthermore, podoplanin combined with binary dysplasia grade obtained a HR of 10.238 (95% CI of 2.06−50.889; p = 0.004). To conclude, CD44v6, p53, p73, and podoplanin showed an increasing expression along the natural history of oral carcinogenesis. Podoplanin expression independently or combined with dysplasia grade could be useful predictive markers of MT in OL.

Exploiting salivary miR-375 as a clinical biomarker of oral potentially malignant disorder

Background/purpose

Oral potentially malignant disorder (OPMD) is an important premalignancy worldwide. MicroRNAs (miRNAs) are endogenously expressed non-coding RNAs that regulate the post-transcriptional levels of targeted mRNAs. MiRNA-375 (miR-375) is markedly downregulated in oral carcinoma tissues and plays an oncogenic role in oral carcinogenesis. We explored the potential of the deregulated salivary miR-375 levels in OPMD patients.

Materials and methods

. We analyzed the levels of miR-375 in the saliva of patients with OPMD (n = 45) and healthy controls (n = 24) by quantitative RT-PCR. The cell lysates and supernatants were treated with the miR-375 mimic and inhibitor.

Results

Salivary miR-375 levels were decreased markedly in the patients with OPMD, compared with the controls. OPMD patients with non-dysplasia showed a higher abundance of miR-375 in the saliva than dysplasia patients, suggesting that salivary miR-375 is a more sensitive marker for OPMD. Patients with malignant transformation during the follow-up period showed lower expression of saliva miR-375 than the others. MiR-375 expression was markedly decreased by treatment with the miR-375 inhibitor, and the supernatants of both NHOK and SAS cells showed a corresponding decline in miR-375 expression.

Conclusion

Our results indicate the potential application of salivary miR-375 as a biomarker for the detection and long-term follow-up of OPMD.

Can tissue biomarkers be used to determine the prognosis of oral leukoplakia lesions with regards to malignant transformation?

Design Systematic review looking at published studies which aimed to identify human tissue biomarkers which could predict malignant transformation of oral leukoplakia (OL) lesions.Case/control selection Articles were identified from PubMed, EBSCO and Cochrane library databases using combinations of keywords. Randomised clinical trials, case-control studies and prospective and retrospective cohort studies were included. All studies had to include follow-up data. There were no restrictions regarding gender, age groups, geographic origin, or year of publication. The selection process involved two of the researchers independently analysing titles and abstracts to identify articles for full-text reading. The same authors then read the articles identified for full-text reading, applying the eligibility criteria. If there was a disagreement with regards to the selection, a discussion was had until a consensus was reached.Data analysis Qualitative data was presented as reported from the primary studies. Quantitative analysis was not carried out due to the high heterogeneity across the studies.Results Forty-six studies were included within the systematic review. These studies identified a total of 3,783 patients with OL, of which 1,047 went on to develop oral cancer, giving an average malignant transformation incidence of 27.6%. Forty-nine different tissue biomarkers were evaluated among the included studies, with the p53 and podoplanin proteins and loss of heterozygosity the most frequently discussed.Conclusions Of the biomarkers studied, podoplanin and chromosomal loci abnormalities (such as loss of heterozygosity) would appear the most promising in being able to predict malignant transformation of OL lesions; however, further research is required.

Prediction of malignant transformation in oral epithelial dysplasia using infrared absorbance spectra

Oral epithelial dysplasia (OED) is a histopathologically-defined, potentially premalignant condition of the oral cavity. The rate of transformation to frank carcinoma is relatively low (12% within 2 years) and prediction based on histopathological grade is unreliable, leading to both over- and under-treatment. Alternative approaches include infrared (IR) spectroscopy, which is able to classify cancerous and non-cancerous tissue in a number of cancers, including oral. The aim of this study was to explore the capability of FTIR (Fourier-transform IR) microscopy and machine learning as a means of predicting malignant transformation of OED. Supervised, retrospective analysis of longitudinally-collected OED biopsy samples from 17 patients with high risk OED lesions: 10 lesions transformed and 7 did not over a follow-up period of more than 3 years. FTIR spectra were collected from routine, unstained histopathological sections and machine learning used to predict malignant transformation, irrespective of OED classification. PCA-LDA (principal component analysis followed by linear discriminant analysis) provided evidence that the subsequent transforming status of these 17 lesions could be predicted from FTIR data with a sensitivity of 79 ± 5% and a specificity of 76 ± 5%. Six key wavenumbers were identified as most important in this classification. Although this pilot study used a small cohort, the strict inclusion criteria and classification based on known outcome, rather than OED grade, make this a novel study in the field of FTIR in oral cancer and support the clinical potential of this technology in the surveillance of OED.

Oral leukoplakia: A clinicopathological study and malignant transformation

OBJECTIVES

To assess the clinicopathological characteristics of a cohort of patients with oral leukoplakia (OL) managed in a Romanian dental hospital and to evaluate the risk of malignant transformation (MT).

MATERIALS AND METHODS

We conducted a hospital-based retrospective study using the clinical charts of patients diagnosed with OL that had complete clinical and histopathological evaluation followed up for 1-16 years.

RESULTS

From 120 included patients, 68 (56.7%) were females, and 71 (59.2%) were current smokers. The homogeneous form was present in 60% of cases; the buccal mucosa was the most frequently involved site. MT was observed in 9 cases, which was more common in females and in those with dysplastic leukoplakia. A significant statistical association was found between MT and dysplasia grade (χ² test: p = 0.007). MT occurred during a mean interval of time 75 months in both treated and non-treated patients.

CONCLUSIONS

In this leukoplakia cohort, most of the lesions encountered were in smokers, clinically homogeneous and 62.5% proved histologically benign. But despite the clinically benign appearance of leukoplakia, tissue diagnosis of some cases was carcinoma. The results of the current study advocate the necessity for biopsy even in apparently homogeneous, clinically benign lesions. The malignization rate was 7.5%; two-thirds were nonhomogeneous lesions.

Oral potentially malignant disorders: advice on management in primary care

Introduction: The diagnosis of and risks associated with oral potentially malignant disorders (OPMD) have been widely reported, but little has been published on the management of OPMDs in a primary dental care setting. Hospital services face ongoing pressures due to long-term follow-up, with a need for surveillance to be jointly undertaken with primary dental care clinicians. In a primary care setting, identification and surveillance of OPMDs can be challenging as no universal guidance exists on recommended recall intervals. Corpus: In this article, an update on OPMDs is provided and, based on the practices of six Oral Medicine units in Europe (London (United Kingdom), Milan (Italy), Bordeaux (France), Porto (Portugal), Zagreb (Croatia) and Santiago de Compostela (Spain)), aiming to provide guidance on monitoring in a primary care setting in Europe. Conclusion: Oral medicine clinicians can provide guidance to general dental practitioners (GDPs) on recommended recall intervals. It is important that they feel confident in monitoring these conditions and, when concerned, to arrange referral to a hospital or appropriate specialist. GDPs should document descriptions of lesions and, if possible, take clinical photographs. Patients should be counselled on modifiable lifestyle factors and directed to oral medicine society websites to access patient information leaflets.

Development and validation of a nomogram prediction model for malignant transformation of oral potentially malignant disorders

OBJECTIVE

Oral potentially malignant disorders have increased the risk of oral squamous cell carcinoma. This study developed a nomogram model to assess the risks of malignant transformation of oral potentially malignant disorders.

MATERIALS AND METHODS

A retrospective analysis of patients diagnosed with oral potentially malignant disorders confirmed by pre-treatment biopsy was performed between 2010 and 2017 at the Peking University Hospital of Stomatology. The candidate risk factors for malignant transformation were screened from clinicopathological variables using Cox and stepwise regression analyses. The nomogram model was constructed based on the regression results and was validated through receiver operating characteristic curves and calibration curves. Decision curve analysis was used to estimate clinical usefulness.

RESULTS

A total of 6964 cases of oral potentially malignant disorders were assessed. The malignant transformation rate of oral potentially malignant disorders was 2.00%. Risk factors (age, site, kind of oral potentially malignant disorder, existence of dysplasia and its grade, and other cancers) derived from the regression analyses were entered into the nomogram model. Time-dependent receiver operating characteristic curve, calibration curve, and decision curve analyses showed high levels of predictive value and clinical relevance, although not for all oral potentially malignant disorders.

CONCLUSION

A specific dynamic nomogram could be adopted to predict the malignant transformation of oral potentially malignant disorders and implement interventions.

The clinical utility of contemporary oral epithelial dysplasia grading systems

INTRODUCTION

Clinical management of oral potentially malignant disorders relies on accurate histopathological assessment of the presence and grade of oral epithelial dysplasia. Whilst adjunctive laboratory tests have provided useful prognostic information, none are in widespread clinical use. This study was performed to assess the clinical utility of two contemporary oral epithelial dysplasia grading systems.

METHODS

Patients were identified from a clinical database. Oral epithelial dysplasia grading was performed by three oral and maxillofacial pathologists blinded to clinical outcome using the WHO 2017 system and a binary classification. The primary outcome measure was the development of oral squamous cell carcinoma, termed 'malignant transformation'.

RESULTS

131 cases satisfied the inclusion criteria, of which 23 underwent malignant transformation. There was substantial inter-rater agreement between the study pathologists for both grading systems, measured using kappa statistics (κ = 0.753-0.784). However, there was only moderate agreement between the consensus WHO 2017 dysplasia grade for the study against the original grade assigned by a pool of six pathologists in the context of the clinical service (κ = 0.491). Higher grade categories correlated with an increased risk of developing cancer using both grading systems.

CONCLUSION

This study demonstrates that the WHO 2017 and binary grading systems are reproducible between calibrated pathologists and that consensus reporting is likely to improve the consistency of grading. The WHO and binary systems were prognostically comparable. We recommend that institutions implement consensus oral epithelial dysplasia grading and prospectively audit the effectiveness of risk stratifying their patients with oral potentially malignant disorders. (249 words).

Expression of spindle assembly checkpoint proteins BubR1 and Mad2 expression as potential biomarkers of malignant transformation of oral leukoplakia: an observational cohort study

Background

The Spindle Assembly Checkpoint (SAC) is a surveillance mechanism essential to ensure the accuracy of chromosome segregation during mitosis. Our aim was to evaluate the expression of SAC proteins in oral carcinogenesis, and to assess their potential in predicting malignant transformation of oral leukoplakia.

Material and Methods

We analysed the immunoexpression of BubR1, Mad2, Bub3, and Spindly proteins in 64 oral biopsies from 52 oral leukoplakias and 12 normal tissues. Univariate and multivariate analysis were performed to evaluate predictive factors for malignant transformation (MT).

Results

We observed that BubR1 and Mad2 were more highly expressed in high dysplasia grade lesions than in low grade or normal tissues (P<0.05). High expression of Spindly was significantly correlated with a high Ki-67 score (P=0.004). Six (11.5%) oral leukoplakias underwent malignant transformation. In univariate analysis, the binary dysplasia grade (high grade) (P<0.001) was associated with a higher risk of malignant transformation as well as high BubR1 (P<0.001) and high Mad2 (P=0.013) expression. In multivariate analysis, high expression of BubR1 and Mad2 when combined showed an increased risk for malignant transformation (P=0.013; HR of 4.6, 95% CI of 1.4-15.1).

Conclusions

Our findings reveal that BubR1 and Mad2 were associated with an increased risk for malignant transformation independently of histological grade and could be potential and useful predictive risk markers of malignant transformation in oral leukoplakias.

Key words:BubR1, Mad2, Spindly, Bub3, Oral Leukoplakia, epithelial dysplasia, Oral squamous cell carcinoma.

Risk factors for oral epithelial dysplasias to become malignant: clinical implications

There is a lack of effective clinical management of oral epithelial dysplasias to reduce their risk of malignant transformation and considerable gaps in knowledge regarding the most effective means of treating such lesions. A retrospective cohort of biopsy-confirmed oral epithelial dysplasias consecutively diagnosed in the period 1995-2014 and followed-up until 2017 was identified from pathology department files. Demographic, clinical and follow-up information was collected. Multivariate Cox proportional-hazards models were performed to evaluate sociodemographic, clinical and pathological factors associated with progression to oral squamous cell carcinoma. The study included 144 oral epithelial dysplasias, of which 42% progressed to oral cancer at the end of follow-up (21 years). Clinical aspect of the lesion was described for 77 (53.5%) of the patients. Treatment, age, grade of the lesion and diagnostic period were independent prognostic factors for progression. When considering only patients with described clinical aspect, only treatment and grade of the lesion were independently associated with cancer. The results from this non-selected retrospective cohort of oral epithelial dysplasias underscore the existing limitations of the current standard-of-care of the patients and provide novel insights on the management of these lesions with and without described clinical aspect. Well-designed, robust prospective studies, a homogenized staging system and multidisciplinary treatment guidelines are warranted.

Identification of specific clinical risk factors associated with the malignant transformation of oral epithelial dysplasia

BACKGROUND

Factors that increase the risk of malignant transformation of oral epithelial dysplasia (OED) are not completely elucidated.

METHODS

A retrospective chart review was performed assessing risk factors for transformation of OED, and cancer staging for transformed cases at Sunnybrook Health Sciences Centre.

RESULTS

Two-hundred four patients were diagnosed with OED, and 16.7% (34) underwent malignant transformation. Risk factors associated with transformation included: heavy tobacco smoking, excessive EtOH consumption, non-homogenous leukoplakia, size >200 mm² , moderate dysplasia or greater than moderate, progression of dysplasia grades, and immunosuppression. Transformed cases followed for a dysplastic lesion were associated with a stage-I cancer diagnosis, and cancer cases with no prior biopsy were associated with a stage-IV diagnosis.

CONCLUSIONS

In addition to commonly cited risk factors, immunosuppression was associated with malignant transformation, including the use of topical steroids. Analyzing risk factors can help clinicians define risk of progression in patients with OED.

Premalignant and malignant lesions of oral cavity in eastern India: a hospital-based study

BACKGROUND

Oral carcinoma and precancers are major public health challenges in India and other developing countries.

OBJECTIVES

Aim of the study was to assess the associations of demographic characteristics, addictions, chief complaints of mouth/oral and clinical diagnosis by cytology smear and punch biopsy in early detection of oral premalignant and malignant lesions. Methods Study was designed on retrospective data of case files of CDC, CNCI, Kolkata, from patients attended from January 1996 to September 2016. History was taken, histopathology and Pap smear were performed. Descriptive statistical analysis, cross-tabulation and Pearson's Chi-square test were done.

RESULTS

Total participants (n = 692); 110 (15.9%) having history of swallowing betel leaf, nut lime, dokta, jarda, catecheu with an average of 11 years. Three hundred twenty-five (46.9%) had multiple addiction (cigarette/bidi/tobacco/all). Ninety-eight (12.1%), 99 (12.2%) and 68 (8.4%) were addicted to cigarette, bidi and chewing tobacco, respectively. Twenty-nine participants were addicted to alcohol; 18 (2.6%) and 11 (1.5%) took country and foreign alcohol correspondingly. Clinicians thoroughly examined lips (4.1%), buccal mucosa (27.3%), gingival (2.8%), tongue (23.1%), hard and soft palate (4.9%), mouth loor (5.2%) and other parts (32.3%); diagnosed participants as normal (22.8%)/benign (23.1%)/premalignant (39.1%)/malignant (14.8%). Smears confirmed 60, 131, 42, 9 and 8 cases as carcinoma, mild, moderate, severe dysplasia and inflammation, respectively. The punch biopsy identified 11 carcinomas, two severe, two moderate and seveeen mild dysplasia's. Chi-square test showed significant association between smear and examination (P = 0.022), diagnosis and examinations of the oral cancer patients (P = 0.0001).

CONCLUSION

The study provided strong evidence that betel leaf, chewing tobacco, smoking and alcohol are independent risk factors for oral cancer. Cytological smear and biopsy are cost-effective approaches for early detection.

RARβ Expression in Keratinocytes from Potentially Malignant Oral Lesions: The Functional Consequences of Re-Expression by De-Methylating Agents

Simple Summary

Patients may develop white or red patches of the lining of the mouth with an increased risk of developing oral cancer. Treatment with Vitamin A derivatives (retinoids) results in some improvement in these lesions, but this is not maintained, and there are side effects. We know that the cells of the mouth lose cellular receptors for retinoids as these lesions develop, initially by a reversible alteration to the DNA (DNA methylation). Drugs, such as 5-AZA-CdR, which reduce DNA methylation, may restore sensitivity to the effects of retinoids. Treatment of a panel of cells from mouth precancer white patches with retinoids, 5-AZA-CdR and a combination results in varied responses: some cells re-sensitise to retinoids, whereas in others, the main effects on cell division rate and cell lifespan seem related to the effects of 5-AZA-CdR alone. These findings help us to understand the varied responses to retinoids in the clinical setting.

Abstract

Loss of RARβ2 expression by promoter methylation is an early event in oral carcinogenesis. Understanding the mechanisms and consequences of RARβ loss may aid in understanding the disappointing results of retinoid chemoprevention trials. This study aimed to describe the effects of all-trans retinoic acid (ATRA) and the de-methylating agent 5-Aza-2′ deoxycytidine (5-AZA-CdR) on a panel of immortal potentially malignant oral lesion (PMOL) cell cultures. RARβ expression was assessed in PMOL tissues by immunohistochemistry. Cells were treated with ATRA ± 5-AZA-CdR, and the effects on the cell cycle and senescence were assessed. In PMOL tissues, RARβ expression was variable, but lower in biopsies which gave rise to immortal cell cultures. Treatment of iPMOL cells with ATRA resulted in little change in RARβ expression, but the addition of 5-AZA-CdR resulted in significant increases. The effects on the cell cycle and senescence were variable and may be related to 5-AZA-CdR, as this has wider effects on the cell cycle. Overall, the response of iPMOL cells to ATRA and 5-AZA-CdR treatment was variable and is dependent on several factors, including RARβ-promoter methylation. These findings may help to explain the lack of consistent effect of retinoids in PMOLs seen in chemoprevention trials.

Improvement in the risk assessment of oral leukoplakia through morphology-related copy number analysis

Oral leukoplakia is the most common type of oral potentially malignant disorders and considered a precursor lesion to oral squamous cell carcinoma. However, a predictor of oral leukoplakia prognosis has not yet been identified. We investigated whether copy number alteration patterns may effectively predict the prognostic outcomes of oral leukoplakia using routinely processed paraffin sections. Comparison of copy number alteration patterns between oral leukoplakia with hyperplasia (HOL, n=22) and dysplasia (DOL, n=21) showed that oral leukoplakia with dysplasia had a higher copy number alteration rate (86%) than oral leukoplakia with hyperplasia (46%). Oral leukoplakia with dysplasia exhibited a wider range of genomic variations across all chromosomes compared with oral leukoplakia with hyperplasia. We also examined a retrospective cohort of 477 patients with oral leukoplakia with hyperplasia with detailed follow-up information. The malignant transformation (MT, n=19) and leukoplakia recurrence (LR, n=253) groups had higher frequencies of aneuploidy events and copy number loss rate than the free of disease (FD, n=205) group. Together, our results revealed the association between the degree of copy number alterations and the histological grade of oral leukoplakia and demonstrated that copy number alteration may be effective for prognosis prediction in oral leukoplakia patients with hyperplasia.

Opportunistic Screening of Oral Potentially Malignant Disorders: A Public Health Need for India

PURPOSE

Oral cancer (OC) is the leading cancer in 25% of Indian cancer registries, and 80% of OCs are diagnosed in advanced stages. OC screening is a topic of debate. Studies from other countries have used a variety of study designs as OC screening strategies. There are not many studies from India on strategic screening, and there is a need to review the literature to provide insights and knowledge about screening programs. The purpose of this narrative review is to present broad epidemiologic evidence on the OC burden in India, to discuss and summarize the currently available evidence for OC screening strategies, and to highlight a feasible opportunistic screening strategy for addressing OC burden in India.

METHODS

Medline and EMBASE were used to identify articles. Data from GLOBOCAN and government reports were obtained from websites. As many key concepts and divergent views cannot be addressed with a single research question, a narrative review was considered appropriate, but to ensure a comprehensive literature search, a systematic review search strategy was used.

RESULTS

OC rates are rising more rapidly in India than projected. Wide variations in OC incidence within India reflect regional diversity of risk factors. Studies abroad have demonstrated the feasibility of opportunistic screening of oral potentially malignant disorders by dentists; however, although recommendations exist in India, no studies of opportunistic screening by dentists have been reported.

CONCLUSION

The projected major increases in the OC burden necessitate an OC screening program; opportunistic screening of high-risk groups by dentists using oral visual examination is recommended as a cost-effective strategy. As a way forward, a pilot project to assess the feasibility of regional opportunistic screening is in progress.