Association of low adherence to weekly cisplatin with outcomes in patients with head and neck squamous cell carcinoma: a retrospective cohort study.

BACKGROUND: The National Comprehensive Cancer Network (NCCN) guideline recommends consideration of weekly cisplatin as an alternative option for patients with head and neck cancer undergoing definitive chemoradiation. However, in a recent phase III trial (ConCERT), 20% of patients treated with weekly cisplatin could not receive a total of 200 mg/m2, and the association of low adherence to weekly cisplatin and cancer control outcomes remains unclear. To fill this knowledge gap, we performed an observational cohort study of patients with head and neck cancer undergoing definitive chemoradiation with weekly cisplatin. METHODS: Our institutional database was queried for patients with non-metastatic head and neck cancer who underwent definitive chemoradiation with weekly cisplatin (40 mg/m2) between November 2007 and April 2023. Adherence to weekly cisplatin was defined as receiving at least 5 cycles with a total cumulative dose of 200 mg/m2. Survival outcomes were evaluated using Kaplan-Meier method, log-rank tests, Cox proportional hazard multivariable (MVA) analyses. Logistic MVA was performed to identify variables associated with low adherence to weekly cisplatin. Fine-Gray MVA was performed to analyze failure outcomes with death as a competing event. RESULTS: Among 119 patients who met our criteria, 51 patients (42.9%) had low adherence to weekly cisplatin. Median follow up was 19.8 months (interquartile range 8.8-65.6). Low adherence to weekly cisplatin was associated with worse overall survival (adjusted hazards ratio [aHR] 2.94, 95% confidence interval [CI] 1.58-5.47, p < 0.001) and progression-free survival (aHR 2.32, 95% CI 1.29-4.17, p = 0.005). It was also associated with worse distant failure (aHR 4.55, 95% CI 1.19-17.3, p = 0.03), but not locoregional failure (aHR 1.61, 95% CI 0.46-5.58, p = 0.46). KPS < 90 was the only variable associated with low adherence to weekly cisplatin (adjusted odds ratio [aOR] 2.67, 95% CI 1.10-6.65, p = 0.03). CONCLUSION: Our study suggested that over 40% of patients underwent fewer than 5 weekly cisplatin cycles and that low adherence to weekly cisplatin was an independent, adverse prognostic factor for worse survival and distant failure outcomes. Those with reduced adherence to weekly cisplatin were more likely to have poor performance status. Further studies are warranted to improve the adherence to chemotherapy and outcomes.

Association of pre-treatment lymphocyte-monocyte ratio with survival outcome in patients with head and neck cancer treated with chemoradiation.

BACKGROUND: Given the role of systematic inflammation in cancer progression, lymphocyte-monocyte ratio (LMR) from peripheral blood has been suggested as a biomarker to assess the extent of inflammation in several solid malignancies. However, the role of LMR as a prognostic factor in head and neck cancer was unclear in several meta-analyses, and there is a paucity of literature including patients in North America. We performed an observational cohort study to evaluate the association of LMR with survival outcomes in North American patients with head and neck cancer. METHODS: A single-institution, retrospective database was queried for patients with non-metastatic head and neck cancer who underwent definitive chemoradiation from June 2007 to April 2021 at the Roswell Park Comprehensive Cancer Center. Primary endpoints were overall survival (OS) and cancer-specific survival (CSS). The association of LMR with OS and CSS was examined using nonlinear Cox proportional hazard model using restricted cubic splines (RCS). Cox multivariable analysis (MVA) and Kaplan-Meier method were used to analyze OS and CSS. Pre-radiation LMR was then stratified into high and low based on its median value. Propensity scored matching was used to reduce the selection bias. RESULTS: A total of 476 patients met our criteria. Median follow up was 45.3 months (interquartile range 22.8-74.0). The nonlinear Cox regression model showed that low LMR was associated with worse OS and CSS in a continuous fashion without plateau for both OS and CSS. On Cox MVA, higher LMR as a continuous variable was associated with improved OS (adjusted hazard ratio [aHR] 0,90, 95% confidence interval [CI] 0.82-0.99, p = 0.03) and CSS (aHR 0.83, 95% CI 0.72-0.95, p = 0.009). The median value of LMR was 3.8. After propensity score matching, a total of 186 pairs were matched. Lower LMR than 3.8 remained to be associated with worse OS (HR 1.59, 95% CI 1.12-2.26, p = 0.009) and CSS (HR 1.68, 95% CI 1.08-2.63, p = 0.02). CONCLUSION: Low LMR, both as a continuous variable and dichotomized variable, was associated with worse OS and CSS. Further studies would be warranted to evaluate the role of such prognostic marker to tailor interventions.

Comparison of different guidelines for oral cancer.

BACKGROUND: Guidelines should provide accessible and reliable information for decision-making. Also, they should be translatable to multiple settings, allowing their use in diverse situations. METHODS: We searched in GOOGLE, PUBMED, SCIELO, and SCOPUS for guidelines on oral squamous cell carcinoma. They were evaluated using the AGREE II protocol. RESULTS: We identified 16 guidelines that fulfilled inclusion criteria. The mean score and range for each AGREE II domain were: "scope and purpose" 74.1% (6-100.0%); "stakeholder" 78.6% (0-100.0%); "rigor of development" 71.4% (0-100.0%); "clarity of presentation" 71.4% (6-100.0%); "applicability" 50.0% (0-85.7%); "editorial independence" 57.1% (14.3-85.7%) and "overall assessment" 57.1% (14.3-100.0%). CONCLUSION: Guidelines for oral cancer present variable quality. Among those available, only four surpassed the 70% AGREE II score threshold.

Recommendations for head and neck surgical oncology practice in a setting of acute severe resource constraint during the COVID-19 pandemic: an international consensus.

The speed and scale of the global COVID-19 pandemic has resulted in unprecedented pressures on health services worldwide, requiring new methods of service delivery during the health crisis. In the setting of severe resource constraint and high risk of infection to patients and clinicians, there is an urgent need to identify consensus statements on head and neck surgical oncology practice. We completed a modified Delphi consensus process of three rounds with 40 international experts in head and neck cancer surgical, radiation, and medical oncology, representing 35 international professional societies and national clinical trial groups. Endorsed by 39 societies and professional bodies, these consensus practice recommendations aim to decrease inconsistency of practice, reduce uncertainty in care, and provide reassurance for clinicians worldwide for head and neck surgical oncology in the context of the COVID-19 pandemic and in the setting of acute severe resource constraint and high risk of infection to patients and staff.

Cancer stem cells and fibroblast niche cross talk in an in-vitro oral dysplasia model.

Understanding the cellular interactions during oral carcinogenesis has the potential to identify novel prognostic and therapeutic targets. This study aimed at investigating the cancer stem cell (CSC)-fibroblast niche interactions using in-vitro dysplastic cell line models developed from different stages of 4NQO-induced oral carcinogenic mice model. The spontaneously transformed epithelial cells (DysMSCTR6, 14 and 16) were developed from three time points (mild/moderate/severe), while two fibroblast cell lines (FibroMSCTR12, 16) were developed from moderate and severe dysplastic tissue. The epithelial (Epcam+/Ck+) and the fibroblast cell lines (Vimentin+/α-SMA+/Ck-) were authenticated and assessment of cells representing progressive grades of dysplastic severity indicated a significant increase in dysplastic marker profile (P < 0.05). Evaluation of the CSC characteristics showed that an increase in expression of Cd133, Cd44, Aldh1a1, Notch1, and Sox2 was accompanied by an increase in migratory (P > 0.05) and colony formation capacity (P > 0.005). Targeting Notch1 (GSI inhibitor PZ0187; 30 µM), showed a significant reduction in cell proliferation capacity (P < 0.05) and in the dysplastic marker profile. Further, Notch1 inhibition resulted in down regulation of Cd133 and Aldh1a 1 (P < 0.05) and a complete abrogation of colony formation ability (P < 0.0001). The effect of niche interactions evaluated using FibroMSCTR12-conditioned media studies, revealed an enrichment of ALDH1A1+ cells (P < 0.05), induction of spheroid formation ability (P < 0.0001) and increased proliferation capacity (3.7 fold; P < 0.005). Although PZ0187 reduced cell viability by ∼40%, was unable to abrogate the conditioned-media induced increase in proliferation capacity completely. This study reports a Notch-1 dependent enrichment of CSC properties during dysplastic progression and a Notch-1 independent dysplastic cell-fibroblast interaction during oral carcinogenesis.

A Novel Mobile Health Approach to Early Diagnosis of Oral Cancer.

AIM: The incidence of oral cancer is high in India, which can be reduced by early detection. We aimed to empower frontline health care providers (FHP) for early detection and connect specialist to rural population through mHealth. MATERIALS AND METHODS: We provided training to FHPs in examination of oral cavity, use of mobile phone for image capture, and risk factor analysis. The FHPs were selected from different cohorts in resource-constrained settings. The workflow involved screening of high-risk individuals in door-to-door and workplace settings, and capture of images of suspected lesions. Uploaded data were interpreted and recommendation was sent by specialist from a remote location. Their recommendation was intimated to FHPs who arranged for further action. Two more initiatives, one for multiple dental schools and another for private practitioners, were undertaken. RESULTS: During the period from 2010 to 2018, 42,754 subjects have been screened, and 5,406 subjects with potentially malignant disorders have been identified. The prevalence of potentially malignant disorders varied from 0.8 to 62% at different cohorts; 516 biopsies have been performed at remote locations. CONCLUSION: Connecting specialists to rural population was made possible through the use of mobile health. Trained FHP were able to reach out to the population. Electronic data capture facilitated efficient follow-up. The program was very cost-effective with screening completed under $1 per person. CLINICAL SIGNIFICANCE: In view of the high incidence of oral cancer in India, and the resource-constrained settings, mobile health paves the way for better access to specialist care for the rural population.

Cancer stem cell mediated acquired chemoresistance in head and neck cancer can be abrogated by aldehyde dehydrogenase 1 A1 inhibition.

Chemoresistance leading to disease relapse is one of the major challenges to improve outcome in head and neck cancers. Cancer Stem Cells (CSCs) are increasingly being implicated in chemotherapy resistance, this study investigates the correlation between CSC behavior and acquired drug resistance in in vitro cell line models. Cell lines resistant to Cisplatin (Cal-27 CisR, Hep-2 CisR) and 5FU (Cal-27 5FUR) with high Resistance Indices (RI) were generated (RI ≥ 3) by short-term treatment of head and neck squamous cell carcinoma (HNSCC) cell lines with chemotherapeutic drugs (Cisplatin, Docetaxel, 5FU), using a dose-incremental strategy. The cell lines (Cal-27 DoxR, Hep-2 DoxR, Hep-2 5FUR) that showed low RI, nevertheless had a high cross resistance to Cisplatin/5FU (P < 0.05). Cal-27 CisR and DoxR showed 12-14% enrichment of CD44+ cells, while CisR/5FUR showed 4-6% increase in ALDH1A1+ cells as compared to parental cells (P < 0.05). Increased expression of stem cell markers (CD44, CD133, NOTCH1, ALDH1A1, OCT4, SOX2) in these cell lines, correlated with enhanced spheroid/colony formation, migratory potential, and increased in vivo tumor burden (P < 0.05). Inhibition of ALDH1A1 in Cal-27 CisR led to down regulation of the CSC markers, reduction in migratory, self-renewal and tumorigenic potential (P < 0.05) accompanied by an induction of sensitivity to Cisplatin (P < 0.05). Further, ex vivo treatment of explants (n = 4) from HNSCC patients with the inhibitor (NCT-501) in combination with Cisplatin showed a significant decrease in proliferating cells as compared to individual treatment (P = 0.001). This study hence suggests an ALDH1A1-driven, CSC-mediated mechanism in acquired drug resistance of HNSCC, which may have therapeutic implications. © 2016 Wiley Periodicals, Inc.

Curcumin and metformin-mediated chemoprevention of oral cancer is associated with inhibition of cancer stem cells.

Effective chemoprevention is critical for improving outcomes of oral cancer. As single agents, curcumin and metformin are reported to exhibit chemopreventive properties, in vitro as well as in patients with oral cancer. In this study, the chemopreventive efficacy of this drug combination was tested in a 4-nitro quinoline-1-oxide (4NQO) induced mice oral carcinogenesis model. Molecular analysis revealed a cancer stem cell (CSC)-driven oral carcinogenic progression in this model, wherein a progressive increase in the expression of CSC-specific markers (CD44 and CD133) was observed from 8th to 25th week, at transcript (40-100-fold) and protein levels (P ≤ 0.0001). Chemopreventive treatment of the animals at 17th week with curcumin and metformin indicated that the combination regimen decreased tumor volume when compared to the control arm (0.69+0.03 vs 6.66+2.4 mm3 ; P = 0.04) and improved overall survival of the animals (P = 0.03). Assessment of the molecular status showed an overall downregulation of CSC markers in the treatment arms as compared to the untreated control. Further, in vitro assessment of the treatment on the primary cells generated from progressive stages of 4NQO-induced mice tissue showed a concordant and consistent downregulation of the CSC markers following combination treatment (P < 0.05). The treatment also inhibited the migratory and self-renewal properties of these cells; the effect of which was prominent in the cultures of early dysplastic tissue (P < 0.002). Collectively, our observations suggest that the combination of curcumin and metformin may improve chemopreventive efficacy against oral squamous cell carcinoma through a CSC-associated mechanism.

The growing burden of cancer in India: epidemiology and social context.

Cancer can have profound social and economic consequences for people in India, often leading to family impoverishment and societal inequity. Reported age-adjusted incidence rates for cancer are still quite low in the demographically young country. Slightly more than 1 million new cases of cancer are diagnosed every year in a population of 1.2 billion. In age-adjusted terms this represents a combined male and female incidence of about a quarter of that recorded in western Europe. However, an estimated 600,000-700,000 deaths in India were caused by cancer in 2012. In age-standardised terms this figure is close to the mortality burden seen in high-income countries. Such figures are partly indicative of low rates of early-stage detection and poor treatment outcomes. Many cancer cases in India are associated with tobacco use, infections, and other avoidable causes. Social factors, especially inequalities, are major determinants of India's cancer burden, with poorer people more likely to die from cancer before the age of 70 years than those who are more affluent. In this first of three papers, we examine the complex epidemiology of cancer, the future burden, and the dominant sociopolitical themes relating to cancer in India.

Whole exome sequencing uncovers HRAS mutations as potential mediators of resistance to metronomic chemotherapy.

OBJECTIVES: The aim of this pilot study is to identify the genetic factors that contribute to the response of metronomic chemotherapy in head and neck squamous cell carcinoma (HNSCC) patients using whole-exome sequencing (WES). This study would facilitate the identification of predictive biomarkers, which would enable personalized treatment strategies and improve treatment outcomes for patients with HNSCC. MATERIALS AND METHODS: We have selected patients with recurrent head and neck cancer who underwent metronomic chemotherapy. Sequential tumor biopsies were collected from the patients at different stages of treatment to capture the genomic alterations and tumor evolution during metronomic chemotherapy and sequenced using WES. RESULTS: We identified several known HNSCC hallmark genes reported in COSMIC, including KMT2B, NOTCH1, FAT1, TP53, HRAS, CASP8, and CDKN2A. Copy number alteration analysis revealed amplifications and deletions in several oncogenic and tumor suppressor genes. COSMIC Mutational Signature 15 associated with defective DNA mismatch repair was enriched in 73% of HNSCC samples. Further, the comparison of genomic alterations between responders and non-responders identified HRAS gene uniquely mutated in non-responders that could potentially contribute to resistance against metronomic chemotherapy. DISCUSSION: Our findings corroborate the molecular heterogeneity of recurrent HNSCC tumors and establish an association between HRAS mutations and resistance to metronomic chemotherapy, suggesting HRAS as a potential therapeutic target. Combining HRAS inhibitors with metronomic regimens could improve treatment sensitivity in HRAS-mutated HNSCC patients. Further studies are needed to fully elucidate the genomic mechanisms underlying the response to metronomic chemotherapy.

Association of Body Mass Index With Outcomes Among Patients With Head and Neck Cancer Treated With Chemoradiotherapy.

Importance: Combined modality therapy, such as chemoradiotherapy, often results in significant morbidity among patients with head and neck cancer. Although the role of body mass index (BMI) varies based on cancer subtypes, its association with treatment response, tumor recurrence, and survival outcomes among patients with head and neck cancer remains unclear. Objective: To evaluate the role of BMI in treatment response, tumor recurrence, and survival outcomes among patients with head and neck cancer undergoing chemoradiotherapy. Design, Setting, and Participants: This retrospective, observational, single-institution cohort study conducted at a comprehensive cancer center included 445 patients with nonmetastatic head and neck cancer who underwent chemoradiotherapy from January 1, 2005, to January 31, 2021. Exposure: Normal vs overweight or obese BMI. Main Outcomes and Measures: Metabolic response after chemoradiotherapy, locoregional failure (LRF), distant failure (DF), overall survival (OS), and progression-free survival (PFS), with Bonferroni correction used to adjust for multiple comparisons and P < .025 being considered statistically significant. Results: A total of 445 patients (373 men [83.8%]; median age, 61 years [IQR, 55-66 years]; 107 [24.0%] with normal BMI, 179 [40.2%] with overweight BMI, and 159 [35.7%] with obese BMI) were included for analysis. Median follow-up was 48.1 months (IQR, 24.7-74.9 months). On Cox proportional hazards regression multivariable analysis, only overweight BMI was associated with improved OS (5-year OS, 71.5% vs 58.4%; adjusted hazard ratio [AHR], 0.59 [95% CI, 0.39-0.91]; P = .02) and PFS (5-year PFS, 68.3% vs 50.8%; AHR, 0.51 [95% CI, 0.34-0.75]; P < .001). On logistic multivariable analysis, overweight BMI (91.6% vs 73.8%; adjusted odds ratio [AOR], 0.86 [95% CI, 0.80-0.93]; P < .001) and obese BMI (90.6% vs 73.8%; AOR, 0.89 [95% CI, 0.81-0.96]; P = .005) were associated with complete metabolic response on follow-up positron emission tomography-computed tomography after treatments. On Fine-Gray multivariable analysis, overweight BMI was associated with reduction in LRF (5-year LRF, 7.0% vs 25.9%; AHR, 0.30 [95% CI, 0.12-0.71]; P = .01), but not DF (5-year DF, 17.4% vs 21.5%; AHR, 0.92 [95% CI, 0.47-1.77]; P = .79). Obese BMI was not associated with LRF (5-year LRF, 10.4% vs 25.9%; AHR, 0.63 [95% CI, 0.29-1.37]; P = .24) or DF (5-year DF, 15.0% vs 21.5%; AHR, 0.70 [95% CI, 0.35-1.38]; P = .30). Conclusion: In this cohort study of patients with head and neck cancer, when compared with normal BMI, overweight BMI was an independent factor favorably associated with complete response after treatments, OS, PFS, and LRF. Further investigations are warranted to improve understanding on the role of BMI among patients with head and neck cancer.

CD44-SNA1 integrated cytopathology for delineation of high grade dysplastic and neoplastic oral lesions.

The high prevalence of oral potentially-malignant disorders exhibits diverse severity and risk of malignant transformation, which mandates a Point-of-Care diagnostic tool. Low patient compliance for biopsies underscores the need for minimally-invasive diagnosis. Oral cytology, an apt method, is not clinically applicable due to a lack of definitive diagnostic criteria and subjective interpretation. The primary objective of this study was to identify and evaluate the efficacy of biomarkers for cytology-based delineation of high-risk oral lesions. A comprehensive systematic review and meta-analysis of biomarkers recognized a panel of markers (n: 10) delineating dysplastic oral lesions. In this observational cross sectional study, immunohistochemical validation (n: 131) identified a four-marker panel, CD44, Cyclin D1, SNA-1, and MAA, with the best sensitivity (>75%; AUC>0.75) in delineating benign, hyperplasia, and mild-dysplasia (Low Risk Lesions; LRL) from moderate-severe dysplasia (High Grade Dysplasia: HGD) along with cancer. Independent validation by cytology (n: 133) showed that expression of SNA-1 and CD44 significantly delineate HGD and cancer with high sensitivity (>83%). Multiplex validation in another cohort (n: 138), integrated with a machine learning model incorporating clinical parameters, further improved the sensitivity and specificity (>88%). Additionally, image automation with SNA-1 profiled data set also provided a high sensitivity (sensitivity: 86%). In the present study, cytology with a two-marker panel, detecting aberrant glycosylation and a glycoprotein, provided efficient risk stratification of oral lesions. Our study indicated that use of a two-biomarker panel (CD44/SNA-1) integrated with clinical parameters or SNA-1 with automated image analysis (Sensitivity >85%) or multiplexed two-marker panel analysis (Sensitivity: >90%) provided efficient risk stratification of oral lesions, indicating the significance of biomarker-integrated cytopathology in the development of a Point-of-care assay.

Inter-observer agreement among specialists in the diagnosis of Oral Potentially Malignant Disorders and Oral Cancer using Store-and-Forward technology.

Oral Cancer is one of the most common causes of morbidity and mortality. Screening and mobile Health (mHealth) based approach facilitates remote early detection of Oral cancer in a resource-constrained settings. The emerging eHealth technology has aided specialist reach to rural areas enabling remote monitoring and triaging to downstage Oral cancer. Though the diagnostic accuracy of the remote specialist has been evaluated, there are no studies evaluating the consistency among the remote specialists, to the best of our knowledge. The purpose of the study was to evaluate the interobserver agreement between the specialists through telemedicine systems in real-world settings using store and forward technology. Two remote specialists independently diagnosed the clinical images from image repositories, and the diagnostic accuracy was compared with onsite specialist and histopathological diagnosis when available. Moderate agreement (k = 0.682) between two remote specialists and (k = 0.629) between the onsite specialist and two remote specialists in diagnosing oral lesions. The sensitivity and specificity of remote specialist 1 were 92.7% and 83.3%, whereas remote specialist 2 was 95.8% and 60%, respectively, compared to histopathology. The store and forward technology and telecare can be effective tools in triaging and surveillance of patients.

Free tensor fascia lata-iliac crest osteomusculocutaneous flap for reconstruction of combined maxillectomy and orbital floor defect.

Reconstruction of maxillectomy with extensive orbital rim and floor excision defects is a challenging problem. The goal of reconstruction here is to provide adequate orbital support to prevent enophthalmos and diplopia as well as obturation of the palatal defect. The existing methods of the reconstruction fail to simultaneously address these 2 goals of reconstruction. A new method of reconstruction of these defects using tensor fascia lata-iliac crest flap was used in 7 cases of cancers of the maxilla, which necessitated extensive resection of the orbital floor along with the maxillectomy. The flap was raised as a muscle and bone flap in 5 cases and in 2, a skin paddle was included. The immediate and delayed outcome at 6-month follow-up was analyzed. The functional outcome with regards to the ocular position and function, palatal obturation, speech, and swallowing were recorded. The bone viability at 6 months was assessed by computed tomography scan. The flap was successful in all the 7 cases. The delayed outcome assessment showed that the orbital support was excellent with no diplopia in all the cases. The palatal defect could be covered successfully in all the cases, resulting in normal speech and swallowing. The computed tomography scan showed excellent integration of the bone. The free tensor fascia lata-iliac crest flap is a reliable and safe method of reconstruction of the orbitomaxillary defects, addressing the issues of both orbital support and palatal obturation.

Non-invasive imaging of oral potentially malignant and malignant lesions: A systematic review and meta-analysis.

Non-invasive (NI) imaging techniques have been developed to overcome the limitations of invasive biopsy procedures, which is the gold standard in diagnosis of oral dysplasia and Oral Squamous Cell Carcinoma (OSCC). This systematic review and meta- analysis was carried out with an aim to investigate the efficacy of the NI-imaging techniques in the detection of dysplastic oral potentially malignant disorders (OPMDs) and OSCC. Records concerned in the detection of OPMDs, Oral Cancer were identified through search in PubMed, Science direct, Cochrane Library electronic database (January 2000 to October 2020) and additional manual searches. Out of 529 articles evaluated for eligibility, 56 satisfied the pre-determined inclusion criteria, including 13 varying NI-imaging techniques. Meta-analysis consisted 44 articles, wherein majority of the studies reported Autofluorescence (AFI-38.6%) followed by Chemiluminescence (CHEM), Narrow Band Imaging (NBI) (CHEM, NBI-15.9%), Fluorescence Spectroscopy (FS), Diffuse Reflectance Spectroscopy (DRS), (FS, DRS-13.6%) and 5aminolevulinic acid induced protoporphyrin IX fluorescence (5ALA induced PPIX- 6.8%). Higher sensitivities (Sen) and specificities (Spe) were obtained using FS (Sen:74%, Spe:96%, SAUC=0.98), DRS (Sen:79%, Spe:86%, SAUC = 0.91) and 5 ALA induced PPIX (Sen:91%, Spe:78%, SAUC = 0.98) in the detection of dysplastic OPMDs from non-dysplastic lesions(NDLs). AFI, FS, DRS, NBI showed higher sensitivities and SAUC (>90%) in differentiating OSCC from NDLs. Analysed NI-imaging techniques suggests the higher accuracy levels in the diagnosis of OSCC when compared to dysplastic OPMDs. 5 ALA induced PPIX, DRS and FS showed evidence of superior accuracy levels in differentiation of dysplastic OPMDs from NDLs, however results need to be validated in a larger number of studies.

Systematic Review and Meta-Analysis to Identify the Immunocytochemical Markers Effective in Delineating Benign from Malignant Thyroid Lesions in FNAC Samples.

Conventional cytology-based diagnosis for thyroid cancer is limited with more than 30-45% of nodules categorized as indeterminate, necessitating surgery for confirming or refuting the diagnosis. This systematic review and meta-analysis were aimed at identifying immunocytochemical markers effective in delineating benign from malignant thyroid lesions in fine needle aspiration cytology (FNAC) samples, thereby improving the accuracy of cytology diagnosis. A systematic review of relevant articles (2000-2021) from online databases was carried out and the search protocol registered in PROSPERO database (CRD42021229121). The quality of studies was assessed using QUADAS-2. Review Manager 5.4.1 from Cochrane collaboration and MetaDisc Version 1.4 was used to conduct the meta-analysis. Bias in the studies were visually analyzed using funnel plots, and statistical significance was evaluated by Egger's test. Systematic review identified 64 original articles, while meta-analysis in eligible articles (n = 41) identified a panel of 5 markers, Galectin-3, HBME-1, CK-19, CD-56, and TPO. Assessment of the diagnostic performance revealed that Gal-3 (sensitivity: 0.81; CI: 0.79-0.83; specificity: 0.84; CI: 0.82-0.85) and HBME-1 (sensitivity: 0.83; Cl: 0.81-0.86; specificity: 0.85; CI: 0.83-0.86) showed high accuracy in delineating benign from malignant thyroid nodules. Efficacy analysis in indeterminate nodules showed Gal-3 and HBME-1 have high specificity of 0.86 (CI 0.84-0.89) and 0.82 (CI 0.78-0.86), respectively, and low sensitivity of 0.76 (CI 0.72-0.80) and 0.75 (CI 0.70-0.80), respectively. Diagnostic odds ratio (DOR) of Galectin-3 and HBME-1 were 39.18 (CI 23.38-65.65) and 24.44 (CI 11.16-53.54), respectively. Significant publication bias was observed for the markers Galectin-3 and CK-19 (p < 0.05). The panel of 5 markers identified from this meta-analysis are high-confidence candidates that need to be validated in thyroid cytology to establish their efficacy and enable clinical applicability.

Establishment and characterization of novel autologous pair cell lines from two Indian non­habitual tongue carcinoma patients.

Oral tongue squamous cell carcinoma (OTSCC) is one of the major causes of fatality in India due to very high percentage of patients with habits of smoking and chewing tobacco and associated products. Being highly heterogeneous in nature, every patient poses a different challenge clinically. To understand disease progression in an improved way, knowledge of cross­talk between tumor stroma and the tumor cells becomes indispensable. Patient­derived in vitro cell line models are helpful to understand the complexity of diseases. However, they have very low efficiency of establishment from the tumor samples, particularly the cancer­associated fibroblasts (CAFs). In the present study, two novel autologous pairs were immortalized spontaneously from non­habitual, HPV­positive patients, who presented with OTSCC. The epithelial and fibroblast cell lines had typical polygonal and spindle­shaped morphology, respectively. Positive staining with epithelial specific Pan­cytokeratin (PanCK) and fibroblast specific protein (FSP­1) further confirmed their epithelial and fibroblast origin. Unique Short Tandem Repeat (STR) profile of the cultures confirmed their novelty, while the similarity of the STR profiles between the epithelial and fibroblast cells from the same patient, confirmed their autologous nature. DNA analysis revealed aneuploidy of the established cultures. An increase in the tumorigenic potential of the established epithelial cultures upon treatment with CAF­conditioned medium proved the 'CAF­ness' of the established fibroblast cells. The established cultures are the first of their kind which would serve as a useful platform in understanding the tumor­stroma cross­talk in tongue cancer progression.

Oral epithelial cell segmentation from fluorescent multichannel cytology images using deep learning.

BACKGROUND AND OBJECTIVES: Cytology is a proven, minimally-invasive cancer screening and surveillance strategy. Given the high incidence of oral cancer globally, there is a need to develop a point-of-care, automated, cytology-based screening tool. Oral cytology image analysis has multiple challenges such as, presence of debris, blood cells, artefacts, and clustered cells, which necessitate a skilled expertise for single-cell detection of atypical cells for diagnosis. The main objective of this study is to develop a semantic segmentation model for Single Epithelial Cell (SEC) separation from fluorescent, multichannel, microscopic oral cytology images and classify the segmented images. METHODS: We have used multi-channel, fluorescent, microscopic images (number of images; n = 2730), which were stained differentially for cytoplasm and nucleus. The cytoplasmic and cell membrane markers used in the study were Mackia Amurensis Agglutinin (MAA; n: 2364) and Sambucus Nigra Agglutinin-1 (SNA-1; n: 366) with a nuclear stain DAPI. The cytology images were labelled for SECs, cluster of cells, artefacts, and blood cells. In this study, we used encoder-decoder models based on the well-established U-Net architecture, modified U-Net and ResNet-34 for multi-class segmentation. The experiments were performed with different class combinations of data to reduce imbalance. The derived MAA dataset (n: 14,706) of SEC, cluster, and artefacts/blood cells were used for developing a classification model. InceptionV3 model and a new custom Convolutional-Neural-Network (CNN) model (Artefact-Net) were trained to classify SNA-1 marker stained segmented images (n:6101). For segmentation models, Intersection Over Union (IoU) and F1 score were used as the evaluation matrices, while the classification models were evaluated using the conventional classification metrics like precision, recall and F1-Score. RESULTS: The U-Net and the modified U-Net models gave the best IoU overall (0.73-0.76) as well as for SEC segmentation (079). The images segmented using the modified U-Net model were classified by Artefact-Net and Inception V3 model with F1 scores of 0.96 and 0.95 respectively. The Artefact-Net, when compared to InceptionV3, provided a better precision and F1 score in classifying clusters (Precision: 0.91 vs 0.80; F1: 0.91 vs 0.86). CONCLUSION: This study establishes a pipeline for SEC segmentation with the segmented component containing only single cells. The pipline will enable automated, cytology-based early detection with reduced bias.

T-Cell Infiltration and Immune Checkpoint Expression Increase in Oral Cavity Premalignant and Malignant Disorders.

The immune cell niche associated with oral dysplastic lesion progression to carcinoma is poorly understood. We identified T regulatory cells (Treg), CD8+ effector T cells (Teff) and immune checkpoint molecules across oral dysplastic stages of oral potentially malignant disorders (OPMD). OPMD and oral squamous cell carcinoma (OSCC) tissue sections (N = 270) were analyzed by immunohistochemistry for Treg (CD4, CD25 and FoxP3), Teff (CD8) and immune checkpoint molecules (PD-1 and PD-L1). The Treg marker staining intensity correlated significantly (p < 0.01) with presence of higher dysplasia grade and invasive cancer. These data suggest that Treg infiltration is relatively early in dysplasia and may be associated with disease progression. The presence of CD8+ effector T cells and the immune checkpoint markers PD-1 and PD-L1 were also associated with oral cancer progression (p < 0.01). These observations indicate the induction of an adaptive immune response with similar Treg and Teff recruitment timing and, potentially, the early induction of exhaustion. FoxP3 and PD-L1 levels were closely correlated with CD8 levels (p < 0.01). These data indicate the presence of reinforcing mechanisms contributing to the immune suppressive niche in high-risk OPMD and in OSCC. The presence of an adaptive immune response and T-cell exhaustion suggest that an effective immune response may be reactivated with targeted interventions coupled with immune checkpoint inhibition.

Evaluation of Optimal Threshold of Neutrophil-Lymphocyte Ratio and Its Association With Survival Outcomes Among Patients With Head and Neck Cancer.

Importance: Given the role of inflammation in cancer progression, neutrophil-lymphocyte ratio (NLR) from peripheral blood has been suggested as a readout of systemic inflammation and a prognostic marker in several solid malignant neoplasms. However, optimal threshold for NLR in US patients with head and neck cancer remains unclear. Objective: To evaluate the optimal NLR threshold as a potential prognostic biomarker for survival outcomes. Design, Setting, and Participants: This retrospective cohort study was conducted at a single institution. Participants included 496 patients with nonmetastatic head and neck cancer who underwent chemoradiation from April 2007 to March 2021. Statistical analysis was performed from September to December 2021. Exposures: High vs low NLR. Main Outcomes and Measures: Overall survival (OS) and cancer-specific survival (CSS). Results: A total of 496 patients (411 male patients [82.9%]; 432 White patients [87.1%]; 64 patients with other race or ethnicity [12.9%]; median [IQR] age, 61 [55-67] years) were identified. Median (IQR) follow-up was 44.4 (22.8-74.0) months. Thresholds of NLR for both OS and CSS were 5.71. High NLR above 5.71 was associated with worse OS (adjusted hazard ratio [aHR], 1.97; 95% CI, 1.26-3.09; P = .003) and CSS (aHR, 2.33; 95% CI, 1.38-3.95; P = .002). On logistic multivariable analysis, patients were more likely to have high NLR if they had higher T and N staging (T3-4: aOR, 4.07; 95% CI, 1.92-9.16; P < .001; N2: aOR, 2.97; 95% CI, 1.04-9.17; P = .049; N3: aOR, 11.21; 95% CI, 2.84-46.97; P < .001), but less likely if they had a good performance status (Karnofsky Performance Status 90-100: aOR, 0.29; 95% CI, 0.14-0.59; P < .001). Among 331 patients (66.7%) with available human papillomavirus (HPV) data, high NLR was not associated with OS (HPV-negative: aHR, 2.46; 95% CI, 0.96-6.31; P = .06; HPV-positive: aHR, 1.17; 95% CI, 0.38-3.56; P = .78) and CSS (HPV-negative: aHR, 2.55; 95% CI, 0.81-7.99; P = .11; HPV-positive: aHR, 1.45; 95% CI, 0.44-4.76; P = .54). Conclusions and Relevance: High NLR was associated with worse survival. Patients with substantial disease burden and poor performance status were more likely to have high NLR. These findings suggest that further studies would be warranted to investigate the role of such prognostic marker to identify patients at risk to tailor interventions.