Comprehensive Prospective Analysis of the Factors Contributing to Aspiration Pneumonia Following Endoscopic Submucosal Dissection in Patients with Early Gastric Neoplasms.

Endoscopic submucosal dissection (ESD) has become the first-line treatment for early gastric neoplasms; however, a subset of patients treated by this method develop aspiration pneumonia. We conducted a comprehensive prospective analysis of the factors contributing to post-ESD aspiration pneumonia in early gastric neoplasms in this study, with special focus on whether pre-treatment oral care can prevent aspiration pneumonia. Sixty-one patients who underwent ESD for gastric neoplasms were randomly assigned to the oral care or control groups. ESD was performed under deep sedation. Of 60 patients whose data were available for analysis, 5 (8.3%) experienced pneumonia confirmed either by chest radiography or computed tomography. Although no difference in the rate of pneumonia was found between the control and oral care groups, the post-oral care bacteria count was significantly higher in the saliva of patients who developed pneumonia compared to those without pneumonia. In addition, the presence of vascular brain diseases and the dose of meperidine were also significantly associated with the occurrence of pneumonia. These results suggest that the number of oral bacteria as well as pre-existing vascular brain diseases and high-dose narcotics can affect the incidence of post-ESD pneumonia.

Metabolomics of Salivary Biomarkers in Yusho Patients.

Yusho patients had many symptoms, and mouth dryness was one of the important oral symptoms. Presently, some Yusho patients complain of mouth dryness. In the present study, we measured mouth dryness by using an oral moisture checking device and examined metabolites of saliva by using metabolome analysis. We found no difference between Yusho patients and controls in terms of mouth dryness. Concerning metabolomes of saliva, there were some metabolites in Yusho patients that were not in controls.

[A clinical study of TMJ arthrosis in Yusho patients].

In the present study, we clarified the TMJ symptoms of Yusho patients. An epidemiologic examination was carried out to identify TMJ arthrosis in patients with Yusho. The patients were collected during annual Yusho examinations in 2012. Nine of 187 patients had TMJ symptoms. The symptoms were pain, trismus, and a clicking sound of the TMJ. We diagnosed these patients with TMJ arthrosis. The rate of TMJ arthrosis in Yusho patients was 4.8%, being similar to the rate of TMJ arthrosis in general. The PCB concentration in the blood of these 9 patients was 2.76 ppb, and the average blood PCB concentration of all patients was 2.98 ppb. We identified no relationship between the blood PCB concentration and TMJ arthrosis.

Efficacy and toxicity of S-1 plus cisplatin combination neoadjuvant chemotherapy in patients with oral cancer.

S-1 is a newly developed oral fluoropyrimidine derivative that is now widely used as a chemotherapeutic agent in the treatment of various carcinomas. This study was performed to assess the efficacy and safety profile of the combination of S-1 and cisplatin(S-1/CDDP)in patients with oral cancer as neo-adjuvant chemotherapy. We reviewed our experience of 12 patients diagnosed with oral carcinoma, who were treated with S-1/CDDP. S-1 was administered orally at a dose of 50mg twice a day for 21 consecutive days, followed by a 14-day rest period. CDDP(60mg/m2)in 500 mL physiological saline was administered by intravenous drip as a 120-min infusion on day 8, together with standard premedications and hydration. Seven partial responders were obtained. The median follow-up duration was 54. 8 months, and all patients were alive excluding one case. This regimen was well tolerated, with only one case of grade 3 thrombocytopenia, and no grade 4 patient. No treatment-related death was observed. Moreover, we evaluated immunohistochemical expressions of thymidylate synthase (TS), dihydropyrimidine dehydrogenase(DPD), and orotate phosphoribosyl transferase(OPRT)which are associated with chemosensitivity to 5-FU-based therapies. We investigated the relation between the immunohistochemical score and clinicopathological factors, however we could not clarify the relationship between the efficacy of chemotherapy and results of immunohistochemistry.

[Immunohistochemical and clinicopathological study of thymidylate synthase, dihydropyrimidine dehydrogenase, and orotate phosphoribosyl transferase expression in oral cancer patients responding to UFT].

Thymidylate synthase(TS), dihydropyrimidine dehydrogenase(DPD), and orotate phosphoribosyl transferase(OPRT)are initial key enzymes in the 5-fluorouracil(5-FU)metabolic pathway. In this study, we investigated clinicopathological and immunohistochemical expressions of TS, DPD, and OPRT in oral cancer patients who showed a complete response(CR)to UFT. We also evaluated patients showing a partial response(PR)and stable disease(SD)following UFT. The numbers of CR, PR, and SD cases were 3, 5, and 10, respectively. Pathologically, all CR and PR cases were the well-differentiated type, and 5 out of 10 SD cases were of the moderately or poorly-differentiated type. Three out of the 5 cases of moderately or poorlydifferentiated type were DPD-negative. Most cases of CR and PR were DPD-positive. OPRT expression showed no difference with the UFT response. We suggest that UFT affects high DPD patients with the well-differentiated type, but may not influence low DPD patients with the moderately or poorly-differentiated type.

Effect of dioxin-related compounds on oral pigmentation in patients affected by the Yusho incident.

BACKGROUND/AIM: Toxins such as polychlorinated biphenyls (PCBs) and dioxins dramatically affect patients even decades after exposure. Patients with Yusho, a condition caused by exposure to PCBs and dioxins, have diverse mental and physical complaints, even though it is almost 50 years since the Yusho incident. Oral pigmentation is one of the major symptoms in Yusho patients. PATIENTS AND METHODS: A total of 183 participants in the Yusho health study were examined. Oral examinations, including recording the prevalence of oral pigmentation, were performed by two oral surgeons. Demographic and clinical characteristics, including blood concentration of PCB and 2,3,4,7,8-pentachlorodibezofuran (2,3,4,7,8-PeCDF), which are the major causes of Yusho, were obtained from the results of recent surveys conducted by the Yusho Study Group. RESULTS: The mean serum PCB and 2,3,4,7,8-PeCDF levels of the 183 Yusho patients were 1.59 ± 1.25 ppb and 29.0 ± 42.9 pg/g lipid, respectively. There was a significant correlation between the levels of PCB and 2,3,4,7,8-PeCDF (r = 0.64, p < 0.01). The rate of oral pigmentation in Yusho patients (25.7%) was significant higher than among potential victims of Yusho (13 of 183, 7.1%) (p < 0.05). CONCLUSION: The prevalence of oral pigmentation was still significantly higher in Yusho patients, even 50 years after exposure, although blood PCB levels have decreased in that time.

Clinical Study of Reconstruction Plates Used in the Surgery for Mandibular Discontinuity Defect.

BACKGROUND/AIM: Postresective mandibular reconstruction is common in cases of oral and mandibular tumors. However, complications such as plate fracture and/or plate exposure can occur. The purpose of this study was to analyze complications and survival of reconstructive plates used to correct mandibular defects caused by oral cancer. PATIENTS AND METHODS: Clinical and radiological data from 34 patients were analyzed. Only discontinuous mandibular defect cases were included in this study. All cases were classified using the Hashikawa's CAT and Eichner's classification methods. Then, we determined whether these classifications and clinical treatment methods were significantly related to complications. RESULTS: Complications after mandibular reconstruction occurred in 10 of 34 patients, specifically, two plate fractures, one screw fracture, and seven plate exposures occurred. The plate fractures occurred 5 and 6 months after operation, and the screw fracture occurred 39 months after operation. Using the Hashikawa's CAT classification, the two cases of plate fracture were one of AT type and the other of T type, and the screw fracture was AT type. Using Eichner's classification, all three cases of plate and screw fractures were B2 type. CONCLUSION: We suggest that plate and screw fractures were caused by the type of mandibular defect and bite force.

Clinicopathologic significance of EpCAM expression in squamous cell carcinoma of the tongue and its possibility as a potential target for tongue cancer gene therapy.

Epithelial adhesion molecule (EpCAM) is a transmembrane glycoprotein involved in intercellular adhesion. In particular, EpCAM appears to be overexpressed by the majority of human epithelial carcinomas, including colorectal, breast, head and neck, and hepatic carcinomas. We therefore hypothesized that EpCAM would be a good molecular target for cancer gene therapy. EpCAM protein expression in 48 primary tongue cancers and 10 normal oral mucosa was evaluated using anti-EpCAM immunohistochemistry, and correlation was examined with the clinicopathologic factors. In four human tongue cancer cell lines (SAS, HSC-2, OSC19 and OSC20), we investigated EpCAM expression by reverse transcription-polymerase chain reaction (RT-PCR). The invasive potential of cancer cells was evaluated using Matrigel invasion assay. Moreover, the effect of EpCAM inhibition was analyzed using RNA interference (RNAi). EpCAM overexpression was detected in 30 of 48 tongue cancers (62.5%), and was significantly higher in primary squamous cell carcinoma (SCC) of the tongue than in normal oral mucosa. The expression of EpCAM was significantly associated with tumor size, regional lymph node metastasis, histological differentiation and invasion pattern. Cancer cell lines with higher EpCAM expression had more invasive potential. Moreover, RNAi-mediated EpCAM reduction decreased the invasion potential and proliferation activity. These results indicated that the overexpression of EpCAM was correlated with a more aggressive phenotype of tongue cancer. Moreover, we suggested that EpCAM could be a molecular target, and that RNAi targeting EpCAM could be useful for tongue cancer gene therapy.

Orotate phosphoribosyl transferase mRNA expression in oral squamous cell carcinoma and its relationship with the dihydropyrimidine dehydrogenase expression and the clinical effect of 5-fluorouracil.

In this study, we investigated whether orotate phosphoribosyl transferase (OPRT) correlates with the clinicopathological features and effect of 5-fluorouracil (5-FU) in human oral carcinoma. We examined the expression of OPRT mRNA by in situ hybridization in surgical specimens of oral squamous cell carcinoma. The expression of OPRT mRNA in oral carcinoma was observed in all specimens and such expression was higher than that seen in normal control tissue specimens. There was no correlation between the expression of OPRT mRNA and clinical factors, but the expression of OPRT mRNA was significantly associated with histological differentiation. The expression of OPRT mRNA showed correlation with effect of 5-FU for oral carcinoma in either in vivo or in vitro. These results suggest that the OPRT expressions may therefore be a prognostic factor of 5-FU efficacy in patients with oral squamous cell carcinoma.

Silencing of the p53R2 gene by RNA interference inhibits growth and enhances 5-fluorouracil sensitivity of oral cancer cells.

The p53R2 gene encodes the ribonucleotide reductase (RR) small subunit 2 homologue, and is induced by several stress signals activating p53, such as DNA-damaging agents. The p53R2 gene product causes an increase in the deoxynucleotide triphosphate (dNTP) pool in the nucleus, which facilitates DNA repair and synthesis. We hypothesized that p53R2 would be a good molecular target for cancer gene therapy. In this study, three human oral cancer cell lines (SAS, HSC-4 and Ca9-22), a human breast cancer cell line MCF-7, and a normal human fibroblast cell line NHDF were tested. We silenced the expression of p53R2 with the highly specific post-transcriptional suppression of RNA interference (RNAi). We investigated p53R2 expression with the reverse transcription-polymerase chain reaction (RT-PCR) and Western blotting. The sensitivity to anticancer agents was evaluated by a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. The expression of p53R2 showed no association with the mutational status of p53. The cancer cell lines with higher p53R2 expression were more resistant to 5-FU. RNAi-mediated p53R2 reduction selectivity inhibited growth and enhanced chemosensitivity in cancer cell lines but not in normal fibroblasts. These results suggest that basal transcription of p53R2 could be associated with the sensitivity to anticancer agents. Moreover, we assessed the possibility that p53R2 would be a good molecular target, and report that RNAi targeting of p53R2 could be useful for oral cancer gene therapy.

Expression of p53R2, newly p53 target in oral normal epithelium, epithelial dysplasia and squamous cell carcinoma.

Recently, the p53R2 gene has been isolated and shown to play a crucial role in DNA repair after DNA damage. The p53R2 gene encodes the p53 inducible ribonucleotide reductase small subunit 2 homologue, which is part of the p53 pathway. However, the function of p53R2 in human cancer is still unclear. We investigated p53R2 mRNA expression in human oral normal epithelium, epithelial dysplasias and squamous cell carcinomas (SCCs). Surgical or biopsy-proven specimens of 10 normal epithelium, 48 epithelial dysplasias and 63 SCCs were collected in our department. Then, p53R2 was identified by in situ hybridization to visualize and localize the expression of specific mRNAs. The authors examined the p53 gene mutation by polymerase chain reaction-single strand conformation polymorphism analysis. p53, mdm2, p21(WAF1/CIP1) and Ki-67 expression was detected by immunohistochemistry. p53R2 expression was detected in none of ten normal epithelium (0%), ten of 48 dysplasias (20.8%) and 33 of 63 SCCs (52.4%). In oral SCC, the expression of p53R2 was significantly associated with tumor size, lymph node metastasis and histological differentiation (P=0.014, 0.046 and 0.022, respectively). p53R2 expression was significantly associated with p53 abnormality in epithelial dysplasia and SCC (P=0.034 and 0.009, respectively). Of 63 patients, 37 received preoperative radiochemotherapy. p53R2 mRNA expression was significantly associated with the pathologic response to radiochemotherapy (P=0.031). This study suggested that p53R2 expression could be associated with oral carcinogenesis. The presence of p53R2 mRNA expression would be a predictive factor for tumor development, tumor cell differentiation and the sensitivity to radiochemotherapy in oral SCC.

Thymidylate synthase and dihydropyrimidine dehydrogenase expression in oral squamous cell carcinoma: an immunohistochemical and clinicopathologic study.

OBJECTIVE: Thymidylate synthase (TS) is the target enzyme for 5-fluorouracil (5-FU), and dihydropyrimidine dehydrogenase (DPD) is the first enzyme that metabolizes 5-fluorouracil. Until now, only the enzyme activities of TS and DPD have been investigated; however, there are few reports about the immunohistochemistry of TS and DPD and none regarding oral carcinoma. The purpose of this article was to investigate the expression of TS and DPD in oral squamous cell carcinoma. STUDY DESIGN: In this study, 109 oral squamous cell carcinomas were investigated for the immunohistochemical expression of TS and DPD proteins. RESULTS: The expressions of TS in carcinoma cases was significantly higher than in controls (P <.05, t test). DPD was expressed both in carcinomas and in areas adjacent to the carcinomas. There was no correlation between the clinical factors and the TS labeling index or between the clinical factors and the DPD labeling index (DPD-LI). Pathologically, DPD-LI was significantly different in both the World Health Organization classification and Anneroth's classification. The TS labeling index was significantly correlated with the Ki-67 LI (P <.05, Pearson's correlation coefficient). Although TS showed no correlation between tegafur-uracil response and TS labeling index, there was a significant correlation between the tegafur-uracil response and DPD-LI. CONCLUSIONS: TS may reveal tumor cell proliferation, but DPD-LI may correlate with a response to anticancer drug treatment.

p53, mdm2, and p21 expression in oral squamous cell carcinomas: relationship with clinicopathologic factors.

OBJECTIVE: The purpose of this study was to clarify the correlation of expression of cell cycle-associated gene proteins with clinicopathologic factors in oral squamous cell carcinoma (SCC). STUDY DESIGN: Formalin-fixed paraffin-embedded tissues from 69 oral SCC cases and 10 normal mucosa cases were stained by immunohistochemistry (IHC) for p53, mdm 2, and p21 proteins. RESULTS: We found p53, mdm 2, and p21 expression in 44 of 69 (63.8%), 25 of 69 (36.2%), and 37 of 69 (53.6%) oral SCCs, respectively. Ki-67-labeling index of combined p53(+)/mdm 2(+) expression cases was significantly higher than those that lacked combined expression (P =.004). Combined p53(+)/p21(+) expression showed a significant association with lymph node metastasis (P =.019). In survival analysis, combined p53(+)/p21(+) and p53(+)/mdm 2(+)/p21(+) expression was associated with poor clinical outcome (P =.018 and.012, respectively). CONCLUSION: Combined p53/mdm 2 expression was associated with tumor proliferation in oral SCC. Combined p53/p21 and p53/mdm 2/p21 expression may be a predictive factor in lymph node metastasis.

Pigmentation of the oral mucosa by PCB poisoning in Yusho patients.

OBJECTIVES: Toxins, such as PCBs, dramatically affect patients even decades after exposure. Although 40 years have passed since the accidental poisoning with polychlorinated biphenyl (PCB) in Western Japan in 1968, high concentrations of PCBs are still detected in the serum of the "Yusho" (oil disease) patients. In this study, an epidemiological examination was carried out to reveal the prevalence of the oral pigmentation and blood concentrations of PCBs and polychlorinated quaterphenyl (PCQ) in Yusho victims. DESIGN: We performed a group examination of patients (Yusho victims) from 2004 to 2006, including 72 Yusho victims and 15 control subjects. The oral examination was performed by two oral and maxillofacial surgeons. The serum concentrations of PCB and PCQ were determined using gas chromatography; blood samples from Yusho victims were analyzed for PCB and PCQ by saponification in 1M NaOH ethanol solution, extraction with n-hexane column chromatography on silica gel, and then gas chromatography with electron capture detection. RESULTS: The mean Yusho victim's serum PCB and PCQ concentrations were 3.3ppb and 0.9ppb, respectively. In controls, these were 0.7ppb and 0ppb, respectively. Oral pigmentation was observed in 24 out of 72 Yusho patients. In controls, oral pigmentation was observed in one out of 15 persons. Oral pigmentation was most frequently observed in the buccal mucosa, followed by gingival mucosa. The blood concentration of PCB in Yusho patients with oral pigmentations was significantly higher than that in Yusho patients without oral pigmentation. CONCLUSION: These results indicated that PCB-related compounds may be responsible for the higher prevalence of oral pigmentation in Yusho victims, even though a long time has passed since the Yusho poisoning accident.

The observational study of delayed wound healing after tooth extraction in patients receiving oral bisphosphonate therapy.

INTRODUCTION: In this study, we investigated whether such a discontinuation of oral bisphosphonate (BP) for 3 months might influence the incidence of BP-related osteonecrosis of the jaw (BRONJ) and wound healing after tooth extraction in patients receiving oral BP therapy. MATERIAL AND METHODS: There were a total of 434 teeth in 201 patients (18 males and 183 females). The patients were divided into two groups depending on whether or not they underwent a 3-month discontinuation of BP therapy (BP- and BP+) before tooth extraction. In this observational study investigated delayed wound healing after tooth extraction in patients receiving oral BP therapy. RESULTS: In all cases of the BP- group, there were no BRONJ although there was delayed wound healing in two cases. However, in one case of the BP+ group, oral BP was continued because it was deemed high risk to discontinue treatment by the patient's physician. In this case, an intraoral fistula was still present with bone exposure at 120 weeks after extraction (BRONJ stage 1). CONCLUSION: This study supports the idea of a drug holiday and encourages further clinical research on this topic of tooth extraction in patients receiving oral BP therapy.

Effect of polyglycolic acid sheets with fibrin glue (MCFP technique) on the healing of wounds after partial resection of the border of the tongue in rabbits: a preliminary study.

The aim of this study was to examine the effectiveness of covering wounds to the tongue with a polyglycolic acid (PGA) sheet and fibrin glue. Eighteen mature male Japanese white rabbits had a unilateral glossectomy involving an area 10mm×10mm×2mm. After glossectomy the tongues were covered with PGA sheets 8mm×8mm in size and fibrin glue (mucosal defect covered with fibrin glue and polyglycolic acid sheet=MCFP) 1 week after the operation (n=3), after 2 weeks (n=3), and after 4 weeks (n=3). In control groups, after 1, 2, and 4 weeks (n=3 in each group), the partially resected tongues were closed with absorbable sutures (polyglactin 910). One week (experimental and control groups 1), 2 weeks (experimental and control groups 2) and 4 weeks (experimental and control groups 3) after operation the tongues were harvested and stained for microscopic examination. Histological examination showed that the covered wound surface had not epithelialised and the basal layer had yet to form in experimental group 1, but had formed in experimental group 2. However, in control group 1, epithelialisation of the sutured wound had begun. Immunohistochemical examination showed that, in experimental group 1, the non-uniform epithelial layer of the covered wound surface expressed cytokeratin AE1/AE3, and the epithelial and connective tissue layers stained strongly for FGF-2. Similar results were obtained in experimental group 2, whereas in experimental group 3, FGF-2 was expressed only in the connective tissue layer, and epithelialisation was complete. However, in control group 1, AE1/AE3 was expressed in the epithelial layer, and FGF was expressed in the connective tissue layer beneath the basal layer. In control groups 2 and 3, AE1/AE3 and FGF-2 were expressed in patterns similar to those in experimental groups 2 and 3. We suggest that this method is useful and the operation is simple. However, further testing of the method is needed and it should be widely used clinically before it is recommended.

Expression of thymidylate synthase and dihydropyrimidine dehydrogenase in primary oral squamous cell carcinoma and corresponding metastases in cervical lymph nodes: association with the metastasis suppressor CD82.

Thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD) are 5-fluorouracil (5-FU) metabolizing enzymes and are involved in the sensitivity of carcinoma patients to 5-FU. Although 5-FU is often used for the treatment of oral carcinoma, there has not been any investigation into the expression of these enzymes in metastatic lymph nodes or of their roles in the effectiveness of 5-FU in treating lymph node-metastatic cancer. Oral squamous cell carcinoma (OSCC) often metastasizes to the lymph nodes, and these enzymes may be significant in the survival of patients with this disease. This study investigated the expression of TS and DPD in cervical lymph node metastases and its relationship with primary OSCC, as well as the interaction between these enzymes and Kangai 1(KAI1/CD82) which is a metastasis suppressor protein. Surgical specimens from 20 cases of OSCC with lymph node metastasis, 20 cases of OSCC without lymph node metastasis, and 10 cases of normal mucosa were examined by immunohistochemistry. The relationship between TS and DPD expression and clinicopathological data was analyzed. TS and DPD proteins were overexpressed in primary OSCC compared to that in normal mucosa. TS expression of the primary oral cancer cells in the group with lymph node metastasis was higher than that of those without. DPD expression did not significantly correlate with the occurrence of lymph node metastasis, nor was it different between primary oral cancer cells and cervical metastases. CD82 expression was significantly reduced in lymph node metastases. These findings indicate that TS and CD82 may be of great value in assessing lymph node metastasis of OSCC, and could be taken as new targets for therapy of metastatic OSCC.

Lingual metastasis as an initial presentation of renal cell carcinoma.

Distant metastasis of malignant neoplasm to the oral soft tissue is extremely rare. We report a case of renal cell carcinoma (RCC) metastasizing to the tongue. A 47-year-old man visited our hospital with chief complaint of a lump on the middle third of the dorsum of his tongue and the lesion fell off from the tongue. Although histopathological diagnosis of the mass was granuloma teleangiectaticum, similar nodule reappeared in the same area 2 weeks later. The second lesion was composed of granuloma teleangiectaticum and aggregation of neoplastic clear cells in ductal arrangement. The clear cells were immunohistochemically positive for EMA and CD10. The abdominal CT scan revealed a 5.5 cm mass in the left kidney, suggesting RCC. Thus, the lingual lesion was consistent with metastatic RCC. There has been no recurrence for 2 years after the radical nephrectomy and local excision of the tongue.

Isolation and characterization of cancer stem-like side population cells in human oral cancer cells.

Recent studies suggest that cancer stem cells may be responsible for tumorigenesis and contribute to some individuals' resistance to cancer therapy. Some studies demonstrate that side population (SP) cells isolated from diverse cancer cell lines harbor stem cell-like properties; however, there are few reports examining the role of SP cells in human oral cancer. To determine whether human oral cancer cell lines contain a SP cell fraction, we first isolated SP cells by fluorescence activated cell sorting, followed by culturing in serum-free medium (SFM) using the SCC25 tongue cancer cell line, so that SP cells were able to be propagated to maintain the CSC property. Differential expression profile of stem cell markers (ABCG2, Oct-4 and EpCAM) was examined by RT-PCR in either SP cells or non-SP cells. Growth inhibition by 5-FU was determined by the MTT assay. Clonogenic ability was evaluated by colony formation assay. SCC25 cells contained 0.23% SP cells. The fraction of SP cells was available to grow in SFM cultures. SP cells showed higher mRNA expression of stem cell markers (ABCG2, Oct-4 and EpCAM) as compared with non-SP cells. Moreover, SP cells demonstrated more drug resistance to 5-FU, as compared with non-SP cells. The clone formation efficiency of SP cells was significantly higher than non-SP cells at an equal cell number (P<0.01). We isolated cancer stem-like SP cells from an oral cancer cell line. SP cells possessed the characteristics of cancer stem cells, chemoresistance, and high proliferation ability. Further characterization of cancer stem-like SP cells may provide new insights for novel therapeutic targets.