Vesiculo-erosive Oral Mucosal Disease—Management with Topical Corticosteroids: (1) Fundamental Principles and Specific Agents Available

Vesiculo-erosive diseases of the oral mucosa pose a major challenge in oral medicine, because they are chronic, painful, and interfere with the daily activities and quality of life of the patients, including disturbing eating, drinking, talking, and personal relationships. Many are autoimmune diseases, and corticosteroid therapy is currently central to their treatment. These diseases present with inflammation and alterations to epithelial integrity, through cell and/or humoral immunity-mediated attack on epithelial-connective tissue targets. Until recently, despite their serious adverse effects, it was necessary to prescribe systemic corticosteroids to control severe erosive oral diseases. Now, however, many of these diseases can be controlled by high-potency topical corticosteroids, which have proved to be highly efficacious and to cause fewer adverse effects compared with systemic corticosteroids. Nevertheless, although topical corticosteroids are still the most widely used drugs in the practice of oral medicine, the scientific body of evidence for their use in the oral cavity is virtually non-existent, and therefore many of the protocols followed are, of necessity, drawn from experience of their use in a dermatological setting. This review aims to set out the key aspects of the use of topical corticosteroids in oral medicine. The issues covered include the indications and basic rules for their use, the types of corticosteroids, the drug selection, and the specific formulations.

Vesiculo-erosive Oral Mucosal Disease—Management with Topical Corticosteroids: (2) Protocols, Monitoring of Effects and Adverse Reactions, and the Future

Although topical corticosteroids (TCs) are the most widely used drugs in oral medicine, and specifically in the treatment of vesiculo-erosive oral mucosal disease, there are few evidence-based data for the correct use of these drugs. In this review, we outline the most widely used protocols, the most common reasons for treatment failure, and the adverse effects documented in the literature.

β-catenin in oral cancer: an update on current knowledge

β-Catenin is a multiple function protein. These functions derive from its interactions with other cell proteins, both on the cell membrane, in the cytoplasm and in the nucleus. β-Catenin forms a complex with the adhesion molecule E-cadherin, promoting cell-cell adhesion and thereby preventing the cell dissociation that is required for cancer invasion and progression mechanisms. There is also a dynamic pool of cytoplasmic β-catenin that serves as connection between the extracellular microenvironment and the nucleus. Cytoplasmic β-catenin acts as a transcription factor for the nucleus in the canonical Wnt pathway, activating the transcription of various genes. Structural or functional alterations of β-catenin can promote cancer progression. This review addresses the current knowledge on the implications of β-catenin in the development of oral cancer.

E-cadherin in non-tumor epithelium adjacent to oral cancer as risk marker for the development of multiple tumors

Our aim was to find out whether the loss of E-cadherin is a risk factor for the development of multiple tumours in the oral cavity and whether it could serve as a diagnostic marker for oral premalignant fields. We studied 77 oral squamous cell carcinomas (SCC) with associated non-tumour epithelia from 61 patients. Immunohistochemical studies (antibody NHC-38) were used to investigate E-cadherin expression, which was completely lost in basal (48% of cases) and parabasal (43%) layers of non-tumour epithelia close to the tumour and in basal (47%) and parabasal (38%) layers of non-tumour epithelia distant from the tumour. In multiple tumours E-cadherin expression was significantly lower than in single tumours in the basal, parabasal layers, and the middle third of close (p=0.002, <0.001, <0.001) and distant (p=0.041, p<0.001, p=0.005) non-tumour epithelia, respectively. Downregulation of E-cadherin may be valuable as a risk marker for the development of multiple tumours in the oral cavity and for the diagnosis of premalignant fields.

Oral ulcers: clinical aspects. A tool for dermatologists. Part I. Acute ulcers

Oral ulcers are generally painful lesions that are related to various conditions developing within the oral cavity. They can be classified as acute or chronic according to their presentation and progression. Acute oral ulcers are be associated with conditions such as trauma, recurrent aphthous stomatitis, Behçet's disease, bacterial and viral infections, allergic reactions or adverse drug reactions. Chronic oral ulcers are associated with conditions such as oral lichen planus, pemphigus vulgaris, mucosal pemphigoid, lupus erythematosus, mycosis and some bacterial and parasitic diseases. The correct differential diagnosis is necessary to establish the appropriate treatment, taking into account all the possible causes of ulcers in the oral cavity. In the first part of this two-part review, acute oral ulcers are reviewed.

Oral ulcers: clinical aspects. A tool for dermatologists. Part II. Chronic ulcers

Oral ulcers are generally painful lesions that are related to various conditions developing within the oral cavity. They can be classified as acute or chronic according to their presentation and progression. Acute oral ulcers are be associated with conditions such as trauma, recurrent aphthous stomatitis, Behçet's disease, bacterial and viral infections, allergic reactions or adverse drug reactions. Chronic oral ulcers are associated with conditions such as oral lichen planus, pemphigus vulgaris, mucosal pemphigoid, lupus erythematosus, mycosis and some bacterial and parasitic diseases. The correct differential diagnosis is necessary to establish the appropriate treatment, taking into account all the possible causes of ulcers in the oral cavity. In this second part of this two-part review, chronic oral ulcers are reviewed.

Update on molecular pathology in oral cancer and precancer

Oral carcinogenesis is a multifactorial process involving numerous genetic events that alter normal functions of oncogenes and tumour suppressor genes. This may increase the production of growth factors or the number of receptors on the cell surface, and/or increase transcription factors or intracellular signal messengers. Together with the loss of tumour suppressor activity, these changes lead to a cell phenotype that can increase cell proliferation, with loss of cell cohesion, and infiltration of adjacent tissue thus causing distant metastasis. Molecular pathology is responsible for defining the molecular mechanisms that underlie the onset of oral precancer and cancer. The aim of this review is to describe recent advances in our understanding of the molecular control of the innumerable pathways related to these processes. These may lead to short- or medium term improvements in the diagnosis and prognosis of oral precancerous and cancerous lesions and to the development of novel therapeutic approaches to this disease.

No differences in caspase-3 and Bax expression in atrophic-erosive vs. reticular oral lichen planus

BACKGROUND

Caspase-3 (CPP32) and Bax expression levels in oral lichen planus (OLP) lesions are considered reliable markers of apoptosis. The malignant transformation of OLP remains a very controversial matter. The objective of this study was to compare histological and apoptotic phenomena between atrophic-erosive and reticular forms of OLP.

METHODS

Analysis was conducted of biopsy samples from 18 patients with reticular and 14 with atrophic-erosive OLP. Conventional histology techniques were used to quantify histological markers of OLP and peroxidase/anti-peroxidase techniques to determine apoptosis markers caspase-3 (CPP32) and Bax.

RESULTS

More Civatte bodies and lymphocyte exocytosis were observed in atrophic-erosive than reticular OLP samples, without any statistical difference. No statistical significant differences in caspase-3 expression were found between these OLP forms in suprabasal layer (58.3% vs. 43.8%), basal layer (83.3% vs. 68.8%) or infiltrate (69.2% vs. 46.6%). Bax expression was relatively infrequent, and no differences were observed between atrophic-erosive and reticular forms.

CONCLUSIONS

The low frequency of apoptotic phenomena (caspase-3 and Bax) in epithelial cells of OLP may create a favourable substrate for malignant transformation. However, there does not seem to be an association with the clinical form (atrophic-erosive or reticular).

CAPN10 alleles modify laryngeal cancer risk in the Spanish population

AIMS

Laryngeal carcinoma is a common upper respiratory tract cancer with different environmental and genetic factors involved in its development. To date, CAPN10 has been found to be extensively associated with hyperinsulinaemia and type 2 diabetes mellitus, by different groups. In addition, some reports have shown evidence that hyperinsulinaemia exerts a protective effect on laryngeal cancer risk. On the other hand, low circulating levels of IGF-1 have been recently found in patients with laryngeal carcinoma. Our objective was to examine the contribution of CAPN10 alleles to the development of laryngeal cancer.

METHODS

Cases and controls were recruited from central and southern Spain. Genotypes were determined using pyrosequencing technology. We analysed CAPN10 UCSNP-44, -43, -19, and -63 allelic distribution in 218 unrelated laryngeal cancer patients and 606 controls from the general population.

RESULTS

We found that the UCSNP-44 allele-C is significantly under-represented among patients with laryngeal cancer (OR=0.685, p=0.02).

CONCLUSION

These results indicate that some CAPN10 alleles may be exerting a protective effect on laryngeal cancer risk in the Spanish population.

Prognostic significance of p21WAF1/CIP1, p16INK4a and CD44s in tongue cancer

The role of lost or reduced expression of p21, p16 and CD44s in the survival of tongue cancer patients was investigated. Tumours and adjacent non-tumour epithelia (ANTE) from 36 patients with tongue cancer were retrospectively studied by immunohistochemistry using monoclonal antibodies against p21, p16 and CD44s proteins. Expression of p21, p16 and CD44s and their relationship with clinical and pathological parameters were analyzed. Of 36 patients, 12 (33.33%) developed recurrence and 12 died of the disease (mean survival, 25.5 months). In four cases (11.1%), concomitant low expression (<50% of tumour cells) of p21, p16 and CD44s was detected but had no effect on survival or recurrence in the univariate analysis. In the multivariate analysis, low expression of CD44s was the sole prognostic factor related to survival (p=0.01, hazards ratio: 0.749). There was no expression of p21, p16 or CD44s in ANTE from 3 out of 24 cases studied, and this finding was related to recurrence in the univariate analysis. In the multivariate analysis, low expression of CD44s in ANTE was again the sole factor related to recurrence (p=0.002, hazards ratio: 0.028). In conclusion, low expression of CD44s is related to tumour cell invasiveness and may be of clinical relevance as a prognostic factor.

Cell cycle regulating mechanisms in oral lichen planus: Molecular bases in epithelium predisposed to malignant transformation

OBJECTIVE

Expression of p53, p21, ki-67, Bcl-2 and caspase-3 proteins in oral lichen planus (OLP) was studied to investigate cell cycle regulation mechanisms in this disease.

MATERIAL AND METHODS

Oral biopsies were obtained from 51 patients with OLP and 26 controls for immunohistochemical analysis (peroxidase antiperoxidase) to quantify expression of the proteins under study (-: 0%, +: <10%, ++: 10-25%, +++: 26-50%, ++++: >50% positive cells).

RESULTS

Basal expression of caspase-3 was negative in 22 cases (46.8%) and positive in <10% of basal cells in 22 cases (46.8%); caspase-3 expression in inflammatory infiltrate was negative in 22 cases (46.8%) and positive in <10% of lymphocytes in 20 cases (42.5%). Basal expression of Bcl-2 was negative in 35 cases (74.5%); Bcl-2 was expressed in inflammatory infiltrate in 34 cases (72.3%) and was positive in <25% of lymphocytes in 14 of these (29.7%). Basal expression of p53 and p21 was positive in 32 (67.9%) and 23 (48.8%) cases, respectively. Basal expression of ki-67 was positive in 45 cases (95.7%), of which 20 (42.5%) showed positivity in >25% of cells; ki-67 was expressed in inflammatory infiltrate in 23 cases (48.9%). Significant associations were found between basal expressions of p53 and ki-67 (p<0.001) and between Bcl-2 expression in infiltrate and basal expression of ki-67 (p<0.001). No association was observed between basal expressions of p53 and caspase-3 (p=0.08). Bcl-2 expression in infiltrate and basal expression of ki-67 were independently associated with presence of OLP.

CONCLUSIONS

Epithelial cells in OLP do not preferentially develop apoptosis but rather cycle arrest or an increased proliferation rate, which may create a suitable substrate for malignant transformation.

A role for substance P in cancer promotion and progression: a mechanism to counteract intracellular death signals following oncogene activation or DNA damage

In the present review we discuss a central role for substance P (SP) in carcinogenesis. We suggest that one mechanism to induce mitogenesis of tumor cells is the activation of neurokinin-1 receptor (NK1R) through SP, linking cancer promotion and progression to a neurokinin-mediated environment. After reviewing the role of both SP and its receptor NK1R in normal and neoplastic cells we propose the use of neurokinin-1 receptor antagonists as a novel and promising approach for treating patients with cancer.

[Suspicion of metastases in laryngeal carcinomas]

OBJECTIVE

To look for models predicting metastasis in laryngeal/hypopharyngeal carcinomas.

DESIGN

Prospective study.

PATIENTS

Sixty patients bearing laryngeal squamous cell carcinoma who were treated with curative purposes were followed prospectively with at least 10-year follow-up.

PARAMETERS

Clinical (Staging, site, age, alcohol and smoking intake, surgery on the primary tumor, neck surgery) and pathological (size, number of metastatic lymph nodes, T and N staging, degree of differentiation, Jakobsson's and Glanz's scoring of malignancy, both scores in biopsies and surgical specimens) parameters were recorded in each case.

METHODS

A multivariate analysis was performed to find out those parameters independently related to presence of metastases.

RESULTS

The prospective study rendered tumor burden and Glanz's scoring from biopsies to be independently related with the presence of metastases.

CONCLUSIONS

Malignancy grading systems must be included in laryngeal carcinoma patients' planning of neck treatment.

Adhesion molecule CD44 as a prognostic factor in laryngeal cancer

BACKGROUND

Loss of expression of CD44 has been shown to be a factor of poor prognosis in some types of tumors. The purpose of this study was to analyze this event in relation to the survival of patients with laryngeal cancer.

PATIENTS AND METHODS

The expression of adhesion molecule CD44 was studied in 137 patients with laryngeal cancer. Data were gathered on clinical (primary tumor location, pyriform sinus involvement and tongue base damage) and pathologic (T, N, differentiation, inflammatory response, tumor thickness, surgical margin involvement, and CD44 expression) parameters. Immunohistochemical studies were carried out using DF1485 anti-CD44 monoclonal antibody.

RESULTS

In 29 tumors (21.1%) < 25%, in 18 (13.1%) 25%-49%, in 42 (30.6%) 50%-74%, and in 48 (35.0%) > or = 75% of the neoplastic cells expressed CD44. A Cox proportional risks multivariate analysis identified CD44 expression and surgical margin involvement as the parameters most associated with survival (p<0.001).

CONCLUSION

The reduced expression of CD44 behaves as a marker of a poor laryngeal cancer prognosis.

Expression of the p53 protein in oral squamous cell carcinomas associated with Epstein-Barr virus

The behaviour of the p53 protein has been investigated in some human carcinomas associated with Epstein-Barr virus (EBV) but not in EBV-positive oral squamous cell carcinomas (OSCC). The present study aimed to compare the p53 protein expression in EBV-positive OSCC with that in EBV-negative OSCC. The cases had been gathered in a study previously published. An immunohistochemical technique with BP53-12 monoclonal antibody was applied on 74 of the 107 OSCC from the earlier work. The nuclear or cytoplasmic expression of the p53 protein was classified as, absent (0% of neoplastic cells positive), mild (<25% positive), moderate (25-30% positive), or extensive (>50% positive). The p53 protein was expressed by 60.8% of the OSCC. Out of the fourteen EBV-positive OSCC, 57.1% (8 cases) expressed p53, always in the nucleus and never in the cytoplasm. Of the 60 EBV-negative OSCC, 61.6% (37 cases) expressed the p53 protein. Of 37 cases 33 (89.1%) showed nuclear expression of p53 and nineteen cases (51.3%) revealed cytoplasmic expression. There was a statistically significant inverse correlation between cytoplasmic expression of the p53 protein and the presence of EBV DNA (p <0.01). Thus, the EBV-positive tumours less frequently expressed p53 in the cytoplasm. No evidence of an accumulation of the p53 protein in OSCC associated with EBV was recorded.

Increase of proliferating cell nuclear antigen (PCNA) expression in HPV-18 positive oral squamous cell carcinomas

Several studies have established a probable relationship between HPV infections and oral neoplasia. The present study analyze the importance of the integration of DNA of HPV type 18 on the proliferative capability of oral squamous cell carcinoma (OSCC) by the study of PCNA expression. Thirty seven patients with OSCC were studied. A complete clinical history and histopathological study was performed. DNA of HPV-18 was found in 7 of the 37 oral OSCCs (19.1%). PCNA expression appeared in 75.7% of OSCCs (28 cases). 9 OSCCs (24.3%) were completely negative, whereas 13 (35.1%), 8 (21.6%) and 7 (18.9%) show minimal, moderate and intense PCNA expression. 4 HPV-18 positive OSCCs showed a intense PCNA expression, 1 OSCC showed moderate PCNA expression, whereas 2 OCSSs showed minimal PCNA expression. Statistical correlations between PCNA expression and DNA HPV-18 amplification showed a more intense PCNA expression in HPV-18 positive OSCCs (p = 0.023). Further studies are needed to establish whether the increase of cellular proliferation induced by HPV-18 has prognostic consequences.

Epithelial response to the immunitary aggression in oral lichen planus

Oral lichen planus is an inflammatory disease with mucous and cutaneous affects caused by cellular immune reaction. Basal cell vacuolation degeneration is the result of T-cell aggression. As the clinical and histopathological alterations of OLP range from epithelial hyperplasia to epithelial atrophy and erosion, it could be that different forms of OLP finally express differences in the intensity of immune attack. The aim of the present study was to analyse the relationship between the clinical and histopathological behaviour and the intensity of the immune response to OLP by means of basal cell vacuolation and inflammatory infiltrate intensity measurement. We analysed 47 patients with OLP. Requirements for inclusion were histopathological diagnosis of OLP from an oral biopsy. Clinical and histopathological correlations were made. OLP's with an intense inflammatory infiltrate were correlated with a high grade of basal cell vacuolations (p < 0.01). A positive statistical correlation between basal cell vacuolation and epithelial atrophy (p < 0.01), and between inflammatory infiltrate intensity and epithelial atrophy (p < 0.01) were observed. An inverse statistical correlation was found when the inflammatory infiltrate intensity and the degree of basal cell vacuolation were compared with epithelial hyperplasia (p < 0.05 and p < 0.01 respectively). In the present study, OLPs with intense immune aggression frequently show epithelial atrophy and erosion on microscopic examination and vice versa.

Proliferating cell nuclear antigen (PCNA) as a marker of dysplasia in oral mucosa

The development of head and neck cancer has been proposed to be a multistep process, with accumulation of genetic and phenotypic alterations resulting from carcinogen exposure. Proliferating cell nuclear antigen (PCNA), also called cyclin, is a 36-KD auxiliary protein of DNA polymerase-delta, that has been found to be a useful marker in immunocytochemical studies of cell proliferation because its expression correlates with the proliferative state of the cell. PCNA expression was analyzed in 10 samples of normal mucosa, 23 benign oral lesions (18 hyperplasia and 5 oral lichen plani), 10 oral lesions with epithelial dysplasia, and 10 dysplastic epithelia adjacent to tumors. Immunocytochemical stained sections were scored for the presence or absence of suprabasal PCNA positivity regardless of location. The results indicate that the PCNA expression in the suprabasal layers increased with the degree of epithelia dysplasia and in the samples of histological dysplastic epithelium adjacent to the tumors, while the percentage of suprabasal PCNA expression was insignificant in the samples of normal oral mucosa and benign oral lesions. The authors conclude that suprabasal PCNA expression could be a marker of dysplasia in oral mucosa, indicating a special proliferative cellular state in those lesions.

Some histopathological and clinical correlations in oral squamous cell carcinoma

Oral squamous cell carcinoma (SCC) is an important health problem that causes high mortality and morbidity. Correlations between some clinical and histopathological parameters were studied in 37 oral SCC. Some interesting aspects in oral SCC arising from precancerous lesions were found such as smaller size and a lower TNM stage at the moment of diagnosis. Histological and clinical differences were also found between tumors invading deep tissues by little groups of dissociated malignant cells and those invading by big masses of malignant cells. The possible significance of the intensity of peritumoral eosinophilic infiltrate was also studied.

Detection of HPV DNA by in situ hybridization in benign, premalignant and malignant lesions of the oral mucosa

Evidence has accumulated in recent years that relates certain types of human papillomaviruses (HPV) to the development of some tumors. We use in situ hybridization to study DNA from HPV 6/11, 16/18 and 31/33/35 in 6 squamous papillomas, 18 hyperkeratotic/acanthosis lesions with and without dysplasia (5 and 13 cases respectively) and 27 squamous cell carcinomas of the oral mucosa. HPV DNA was found in 66% of squamous papillomas, 38.4% of hyperkeratotic/acanthosis lesions without dysplasia, 60% of epithelial dysplasia and 37% of squamous cell carcinomas. HPV DNA 6/11 was the most common type found, and in squamous cell carcinomas HPV DNA appear more frequently in well differentiated tumors.