CD44 expression and its relationship with MMP-9, clinicopathological factors and survival in oral squamous cell carcinoma.

We investigated the expression of CD44 and MMP-9 in primary oral squamous cell carcinoma (OSCC) and evaluated their association with each other and clinicopathological factors as well as their prognostic value during long term follow up. Histological samples from 138 OSCC patients were immunohistochemically stained for the expression of CD44 and MMP-9. The staining results were compared with conventional prognostic factors and their impacts to patients' prognosis were also studied with survival analyses. Irregular staining of CD44 in tumour cells was associated with poor tumour differentiation (p=0.003), higher clinical stage (III-IV) (p=0.049), and the presence of T3-4 tumour stage (p=0.03). Strong stromal MMP-9 staining intensity was correlated with poor tumour differentiation (p=0.03). In univariate survival analysis irregular staining of CD44 in tumour cells was related to poor disease free and overall survival (p=0.001 and p<0.001, respectively). In multivariate analysis CD44 staining was a significant independent predictor for overall (p=0.03) and disease free survival (p=0.003). MMP-9 expression showed no statistical significance in survival analyses. Strong stromal staining intensity of MMP-9 correlated with irregular staining of CD44 in tumour cells, but had no prognostic significance in the present cohort. However, irregular staining of CD44 predicted more advanced disease and shortened survival of the patients.

Versican expression in pharyngeal squamous cell carcinoma: an immunohistochemical study.

AIMS: To study the expression of versican, a large proteoglycan involved in repressing adhesion between cells and the extracellular matrix in pharyngeal squamous cell carcinoma (PSCC), and its relation to the expression of p53 and catenins, histological differentiation, clinical data, and prognosis. METHODS: For the retrospective survey, primary tumours for analyses were obtained from 118 patients diagnosed with PSCC of the oropharynx or hypopharynx. The immunohistochemical expression of versican was studied and was related to the expression pattern of p53 and catenins, in addition to clinical data and survival. RESULTS: In the primary tumours, strong stromal versican expression was graded as low in 59 (50%) and high in 59 (50%) cases. In addition, intracellular versican staining was seen in nine (8%) tumours. In local lymph node metastases, strong stromal versican staining was significantly more frequent compared with the primary tumours (p = 0.018). Strong stromal versican staining was more frequently seen in less advanced tumours (p = 0.015). There was no association between versican expression and the other investigated variables (p53, catenins, TNM status, and histological grade). Neither stromal nor intracellular versican expression predicted overall survival in these patients. CONCLUSIONS: Versican was more strongly expressed in the stroma of local metastases and in the earlier stages of disease in PSCC. However, versican expression was not an independent prognostic factor in this entity.

Reduced expression of hyaluronan is a strong indicator of poor survival in oral squamous cell carcinoma.

Several malignant tumours accumulate hyaluronan (HA), a matrix component suggested to promote cancer cell growth and migration. The expression and prognostic value of HA was analysed in a cohort of 151 oral squamous cell carcinoma (SCC) patients with adequate archival tumour material and follow-up data. The tumour samples were stained using a biotinylated HA-specific probe. Normal squamous epithelium showed a strong and homogeneously distributed staining for HA. The most superficial layers were HA-negative. In moderate (n=11) and high grade (n=16) dysplasias an irregular HA staining was observed around invasive cancer. Malignant transformation in oral squamous cell epithelium changed the staining toward irregular with focal reduction of HA. The well (n=92) or moderately differentiated (n=47) carcinomas had a strong HA staining intensity. In poorly differentiated tumours (n=12) the HA staining was weaker and mainly intracellular. The stromal tissue showed usually moderate (n=69) or strong (n=67) HA staining intensity with no statistically significant correlation with the degree of tumour differentiation. At the end of the follow-up (median 52 months) 66 (43%) patients had died because of an oral SCC. A significant difference in overall survival (OS) and disease free survival (DFS) (P=0.0002 and 0.0020, respectively) was noticed between the patients with the different epithelial staining patterns for HA. The reduction of HA staining was associated with poor survival. In Cox's multivariate analysis HA staining was a significant independent predictor of OS (P=0.011) and DFS (P=0.013). These results suggest that HA is a prognostic marker in oral squamous cell carcinoma.

Supraglottic and glottic carcinomas. clinically and biologically distinct entities?

This study aimed to examine the clinical and biological differences in 198 patients with either T1-T2 local glottic or supraglottic squamous cell carcinomas. The patients with supraglottic cancer had a poorer prognosis, as well as more advanced and histologically aggressive tumours than the patients with glottic tumours. They also had lower levels of haemoglobin and a poorer nutritional and performance status. Expression of alpha-catenin, hyaluronan, CD44, p53, p21/WAF1 and bcl-2 in the primary tumour were not associated with the site of the laryngeal carcinoma. In supraglottic tumours, the rate of spontaneous apoptosis and mitotic indices were significantly higher than in glottic tumours. The results suggest that clinical parameters including the haemoglobin level of the patient together with the tumour cell kinetics (mitotic and apoptotic rates) may contribute to the aggressive nature of supraglottic carcinoma.

Endoscopic laser surgery for laryngeal cancer.

Endoscopic laser surgery is a novel treatment modality for laryngeal cancer. CO2 laser combined with an operating microscope is the most frequently used instrumentation. In Finland we started large-scale laser surgery in 1994 in all five university hospitals, covering a population of about five million people. By 1998 we had operated on 140 patients, of whom 11 were females. Eighty-three per cent of the lesions were glottic. Because of the low number of stage III-IV patients, the recurrence and survival analyses included 132 patients with in situ, stage I or stage II tumours, numbering 8, 96 and 28 respectively. The mean follow-up time was 38 months. The 2-year recurrence frequencies were 5% for stage I, 31% for stage II, and 11% altogether. No patients developed recurrences after 2 years. Seven patients underwent a salvage laryngectomy and the adjusted cumulative survival rate was 95%. After laser surgery the quality of voice was good or excellent in 70% and only three patients suffered from severe aphonia. This study showed that the results of endoscopic laser surgery are comparable with those of radiation therapy, but this type of treatment is more convenient for the patients and much cheaper for society.

Nuclear beta catenin expression is related to unfavourable outcome in oropharyngeal and hypopharyngeal squamous cell carcinoma.

AIMS: To investigate the expression of alpha, beta, and gamma catenins in oropharyngeal and hypopharyngeal squamous cell carcinoma and their relations to each other, as well as to clinical data, tumour differentiation, and prognosis. METHODS: Primary tumours for analysis were obtained from 138 patients diagnosed with squamous cell carcinoma of the oropharynx or hypopharynx between 1975 and 1998 in eastern Finland. Immunohistochemistry was used to evaluate the expression of alpha, beta, and gamma catenins. The expression patterns of all catenins were related to clinical data and survival. RESULTS: The expression patterns of all three catenins were significantly interrelated. Reduced gamma catenin expression was significantly associated with poor histological differentiation. No association was found between alpha or beta catenin expression and clinicopathological characteristics. In univariate analysis, patients whose tumours had nuclear beta catenin expression had shorter overall survival than patients with no nuclear expression. In Cox multivariate analysis, nuclear beta catenin expression, tumour status (T class), and Karnofsky performance index were independent prognostic factors of overall survival. CONCLUSIONS: Reduced expression of gamma catenin is associated with dedifferentiation in primary squamous cell carcinoma of the oropharynx and hypopharynx. The fact that nuclear beta catenin expression independently predicts short overall survival suggests that it might be a valuable prognostic marker in pharyngeal squamous cell carcinoma.

The incidence and etiology of postlaryngectomy pharyngocutaneous fistulae.

BACKGROUND: The pharyngocutaneous fistula is troublesome complication after total laryngectomy. Despite a large number of studies, there is still disagreement on factors predisposing to this complication. METHODS: A retrospective analysis of pharyngocutaneous fistulas in 133 patients in whom total laryngectomy was performed. RESULTS: Fistulas were found in 15% of the patients. Spontaneous closure was noted in 80%. Simultaneous laryngectomy and partial pharyngectomy or neck dissection increased the risk of fistula formation. Preoperative irradiation, short interval between radiotherapy and operation, and cobalt/roentgen radiation instead of photons predispose to this complication. The fistulas appeared earlier, and the sizes of fistulas were significantly larger in patients with previous irradiation than those in patients with no preoperative irradiation. CONCLUSIONS: Postoperative pharyngocutaneous fistulas significantly increase patients' morbidity and hospital stay. Good surgical technique and postoperative treatment should be paid attention to patients with an increased risk of pharyngocutaneous fistula formation.

Surgical management of irradiation failures in T1-T2 squamous cell carcinoma of the glottic larynx.

BACKGROUND: The purpose of this study was to analyse the results of salvage surgery after failure of irradiation to control the primary T1-T2 glottic cancer. MATERIALS AND METHODS: Ninety-eight patients with T1 and T2 squamous cell cancer of the glottic larynx were treated with curative intent by radiotherapy. The tumour recurred in 22 of the 98 (22%) patients. Surgical management consisted of total and frontolateral laryngectomy. Survival rates were calculated from the date of the salvage operation. RESULTS: Two of the 22 patients refused to undergo salvage surgery and one patient had pulmonary metastasis. Of the 19 patients who underwent salvage surgery, 14 (74%) had total laryngectomy and 5 (26%) had frontolateral laryngectomy. The operations were curative in 15 (79%) of the 19 patients. The overall 5-year survival rate after surgery was 78%. CONCLUSION: Stringent follow-up of patients with irradiated T1 and T2 glottic laryngeal cancer is essential to permit a successful salvage.

Hypothyroidism after radiotherapy for laryngeal cancer.

PURPOSE: To investigate the incidence of hypothyroidism after radiotherapy of laryngeal cancer, including the possible factors that could predict the onset of hypothyroidism. MATERIALS AND METHODS: We report this study on patients treated by radiotherapy as part of the treatment for laryngeal cancer in the Department of Oncology in Eastern Finland. Sixty-five males and seven females were treated with radiotherapy between 1974-1995.Thyroid function was determined by measuring serum thyroid stimulating hormone, and serum free thyroxine (FT4). The studied risk factors for hypothyroidism included age, treatment modalities, radiation dose and energy, height of the radiation field, and follow-up time. RESULTS: Hypothyroidism was detected in 17 (24%) of the 72 patients. Hypothyroidism was clinically unsuspected in all but one patient. Hypothyroidism was more common, if the height of the radiation field was >/=7 cm, or the patient had been operated. Hypothyroidism was less common if less than a half of the thyroid bed was irradiated. CONCLUSION: The detection of hypothyroidism clinically is difficult, and the rate of hypothyroidism warrants routine assessment of thyroid function after irradiation of laryngeal cancer.

Merkel cell carcinoma of the auricle.

Merkel cell carcinoma is a rare, although increasingly recognized, malignant tumor of the skin. The most common site of occurrence is the head and neck (50%). Only five cases of this tumor on the auricle have been reported previously. We present a further such case. The incidence, clinical features, diagnosis, prognosis, and treatment of the Merkel cell carcinoma are discussed.

Is the subsite distribution of laryngeal cancer related to smoking habits?

In Finland traditionally as many as two-thirds of laryngeal cancers have been considered to be supraglottic, while in other countries the majority are glottic. The Finnish observation is based on clinical series diagnosed and treated mainly before the 1960s. The aim of our study was to evaluate the present situation. This study consisted of 279 patients treated in Eastern Finland between 1975 and 1994 and included 145 (52%) glottic, 124 (44%) supraglottic and 10 (4%) subglottic tumours in 260 (93%) men and 19 (7%) women. During this study period, the proportion of glottic tumours remained stable in men but increased in women. The change in smoking habits seems to be the most important reason for the shift from supraglottic to glottic tumours.

Ketoprofen and fentanyl for pain after uvulopalatopharyngoplasty and tonsillectomy.

OBJECTIVES: The treatment of postoperative pain after uvulopalatopharyngoplasty (UPPP) and tonsillectomy presents a challenge. Opioids can cause sedation and respiratory depression. Nonsteroidal antiinflammatory drugs can increase postoperative bleeding. The authors have evaluated the severity of postoperative pain and the consumption of opioid in 53 adult patients undergoing either UPPP or tonsillectomy. STUDY DESIGN: A prospective, parallel-groups study. METHODS: A general endotracheal anesthesia was used in each patient. After surgery patients received ketoprofen 1 mg/kg as an intravenous bolus, followed by a continuous infusion of 4 mg/kg during 24 hours. For rescue analgesia patient-controlled intravenous fentanyl was used. RESULTS: Both UPPP and tonsillectomy are associated with intense postoperative pain. More than 40% of the patients had high pain scores during the first 24 postoperative hours. Postoperative pain after UPPP was more severe and the difference was significant during swallowing (P < .05). The need for fentanyl in the UPPP group was twice that of the tonsillectomy group (P < .01). There was a high interindividual scatter in the patient-controlled fentanyl attempts in both groups. The patients in the UPPP group needed significantly more oxygen supply during recovery (P = .007). No serious adverse effects occurred and none of the patients experienced postoperative bleeding that required any intervention. CONCLUSION: Individually tailored analgesic treatment protocol is essential for patients undergoing UPPP and tonsillectomy to ensure safe and effective pain alleviation.

Downregulation of p21/WAF1 is related to advanced and dedifferentiated laryngeal squamous cell carcinoma.

AIM: To analyse p21/WAF1 expression and its relation to p53, apoptosis, cell proliferation, clinicopathological characteristics, and patient survival in human laryngeal squamous cell carcinoma. METHODS: Primary tumours for analyses were obtained from 172 patients with complete follow up data. All patients were treated between 1975 and 1995. Immunohistochemistry was used to evaluate the expression of p21/WAF1, bcl-2, and p53 proteins. The proliferative activity was determined using Ki67 and PCNA antibodies as well as volume corrected mitotic count (M/V index). Volume corrected apoptotic count (A/V index) was determined using an enzymatic in situ cell death detection kit based on the TUNEL method. RESULTS: High p21 expression was significantly related to high p53 and normal bcl-2 expressions as well as low mitotic count. No association was noticed between p21 expression and apoptotic rate. A significant inverse correlation between p21 expression and advanced stage and poor differentiation was observed, but p21 expression showed no correlation with survival. CONCLUSIONS: The expression of p21 was associated with tumour stage, histopathological grade, node status, and mitotic count, which may indicate a role for p21 in the progression of laryngeal squamous cell carcinoma.

Changing trends in the occurrence and subsite distribution of laryngeal cancer in Finland.

Cancer of the larynx represents worldwide approximately 1-2% of all cancers and generally occurs predominantly in males. Based upon many reports, the age-adjusted incidence of laryngeal cancer has been rising in recent years, especially among women. Squamous cell carcinomas arising in the glottic region are the most common of all laryngeal cancers and more prevalent than the supraglottic ones. Subglottic disease is still rare. The Finnish Head and Neck Oncology Group evaluated the present occurrence of laryngeal cancer by site and gender in Finland. The annual age-standardized incidence of laryngeal cancer is 3.2 per 100,000 for men and 0.3 per 100,000 for women. The proportion of females in the five university centers reviewed was 5%. During the 30-year time period from the early 1960s to the 1990s there has been a significant decrease in the laryngeal cancer incidence rates for males, but no change for females. Finland thus seems to be the only Western country with clearly declining occurrence rates in recent decades. In the same time period a clear decrease in the incidence of bronchial cancer has occurred in males and an increase in females. The results also show that in all five university hospital districts glottic cancer became more common (50-68%) in the late 1980s and 1990s, which is opposite to the situation in the 1960s when supraglottic localizations (65%) dominated in Finland.

Enhanced apoptosis correlates with poor survival in patients with laryngeal cancer but not with cell proliferation, bcl-2 or p53 expression.

The purpose of the current study was to analyse apoptosis and bcl-2 expression in laryngeal squamous cell carcinoma (SCC) with special reference to their prognostic significance, correlation with the clinical and pathological characteristics as well as cell proliferation and p53 accumulation. 172 patients with primary laryngeal SCC were followed-up for a median of 67 months. The volume corrected apoptotic (A/V) index was analysed using an in situ end labelling method (TUNEL) in 85 randomly selected patients. The expression of bcl-2 and p53 was analysed with monoclonal antibodies. The proliferative activity was measured both with Ki-67 (MIB-1) antibody and the volume corrected mitotic (M/V) index. The A/V index was not associated with p53 (P = 0.6) or bcl-2 (P = 0.6) expression or with proliferative parameters (P = 0.9 for M/V and P = 0.3 for MIB-1). The 10-year overall survival in patients with a high A/V index was poorer when compared with patients with a low index (47% versus 81%, P = 0.005), while accumulation of bcl-2 had no prognostic significance (P = 0.5). In Cox multivariate analysis of the whole cohort, stage (P < 0.0005) and histological grade (P = 0.04) were predictors of overall survival. In the subset of patients with an A/V index available, predictors of survival were stage (P = 0.05), A/V index (P = 0.02) and histological grade (P = 0.04). A high A/V index was an independent predictor of poor survival in laryngeal SCC. This effect was not associated with tumour cell proliferation. Accumulations of p53 and bcl-2 were not associated with apoptosis. Expression of bcl-2 lacks any prognostic significance in laryngeal SCC. We propose that assessment of the A/V index may help in selecting patients with poor prognosis.

Irregular expression of hyaluronan and its CD44 receptor is associated with metastatic phenotype in laryngeal squamous cell carcinoma.

The distributions of hyaluronan (HA) and its CD44 receptor were studied in 24 normal, 27 dysplastic samples of laryngeal epithelium and in 172 squamous cell carcinomas (LSCC), using a specific probe prepared from cartilage proteoglycan (bHABC, biotinylated hyaluronan binding complex) and a monoclonal antibody (Hermes 3). HA and CD44 were expressed similarly in all normal and about 90% of dysplastic and neoplastic laryngeal epithelia. In the normal epithelium HA and CD44 were homogeneously distributed throughout the epithelium, whereas the most superficial layers were negative. This was in contrast to the picture in dysplastic epithelium and well-differentiated invasive carcinomas, which were entirely HA and CD44 positive. Local areas with a low signal for HA and CD44 were present in 11% and 22% of the samples with dysplasia, and in 27% and 28% of those with carcinoma, respectively. The presence of this staining irregularity was associated with poor differentiation of the carcinoma, a significantly elevated mitotic index and a high frequency of nodal spreading and metastases. Furthermore, the irregular staining showed a trend towards poor disease-free survival, suggesting that an altered metabolism of HA is a common feature in LSCC and is associated with an aggressive growth pattern.

Cytoplasmic accumulation of alpha-catenin is associated with aggressive features in laryngeal squamous-cell carcinoma.

Aberrations in the function of alpha-catenin (alpha-cat), the anchoring protein of E-cadherin, are believed to cause dysfunction of the cadherin-catenin complex, leading to disturbed cell-cell adhesion. It has been suggested that expression of alpha-cat in human tumours might be a better indicator of aggressive phenotype than expression of E-cadherin. The value of alpha-cat as a prognostic marker in laryngeal squamous cell carcinoma (LSCC) is unclear. To determine the potential prognostic significance of alpha-cat, paraffin-embedded samples from 159 patients with invasive carcinoma left in the section and with long-term follow-up were evaluated immuno-histochemically for alpha-cat expression, and the results were related to histopathological grade, tumour stage and survival. Two patterns of staining were observed: pure membranous staining (57%) and membranous staining with cytoplasmic involvement (43%). Cytoplasmic involvement of alpha-cat was associated with dedifferentiation, advanced tumour stage and nodal status. In addition, supra-glottic tumours showed more often cytoplasmic involvement of alpha-cat than glottic tumours. Patients with cytoplasmic involvement appeared to have a trend towards poor overall survival, though without statistical significance. These results suggest that cytoplasmic involvement of alpha-cat is associated with aggressive behaviour and metastatic phenotype of LSCC.

p53 expression and cell proliferation as prognostic factors in laryngeal squamous cell carcinoma.

PURPOSE: To investigate the prognostic significance of p53 expression and proliferation markers in primary laryngeal squamous cell carcinoma. PATIENTS AND METHODS: Primary tumors for analyses were obtained from 103 patients, with complete follow-up data. All patients were treated between the years 1975 and 1990. The expression of p53 was analyzed with monoclonal D07 antibody and proliferative activity with Ki-67 (MIB-1) and PCNA (monoclonal 19A2) antibodies. Volume corrected mitotic (M/V) index and histological grade were determined in hematoxylin and cosin-stained slides. RESULTS: Sixty-eight percent of the tumors overexpressed p53. During a median follow-up of 62 months, 41 (40%) of patients relapsed. In univariate analysis site of the primary tumor, stage, p53 expression, histologic grade, and M/V index were significant predictors of disease-free survival. In multivariate analysis, only M/V index was a statistically significant predictor of disease-free survival. Overall survival was significantly better for those overexpressing p53 (10-year cumulative survival rate 68% v 44%, P = .004). In multivariate analysis, M/ V index (P = .02), p53 (P = .02), and stage (P = .007) were statistically significant predictors of overall survival. When this analysis includes stratification according to the type of treatment received, M/V index (P = .007), stage (P = .0002), and p53 (P = .006) were even more significant predictors of overall survival. No association between p53 status and proliferative activity was found. CONCLUSION: Overexpression of p53 is associated with favorable disease-free and overall survival in laryngeal squamous cell carcinoma. It may also have an independent prognostic value in laryngeal cancer. M/V index, p53 overexpression, and stage predict with significant accuracy the 10-year overall survival.