Characterization of stromal calcifications in odontogenic keratocyst: a multicentric study.

Odontogenic keratocysts (OKCs) are locally aggressive cysts that exhibit typical histopathological features and have a propensity for recurrence. Though histological variations are observed in OKCs, hard tissue formation and metaplastic changes are rare, and the underlying pathogenesis is not well understood. This study aimed to characterize stromal calcifications and analyze their association with odontogenic components in non-syndromic and syndrome-associated cases of OKCs. We analyzed 153 cases of OKCs from healthcare institutes in India and Japan. The epithelial and stromal features were evaluated, and the relationship of calcifications with odontogenic rests was determined. Immunohistochemistry for cytokeratin-19 and special stains including Masson Trichrome and Van Gieson, were used for identification of odontogenic rests and calcifications respectively. Stromal calcifications were observed in 29.41% OKCs. The calcification patterns included irregular dystrophic, dentinoid with linear or calcospherite-type mineralization, and psammoma calcifications. Psammoma and dentinoid calcifications were found in the proximity of cytokeratin-19-positive odontogenic rests or satellite cysts, whereas majority cases with dystrophic calcifications did not exhibit co-localization with stromal odontogenic components. Distinct patterns of calcifications were observed in OKCs. Calcifications found in proximity of the odontogenic rests were possibly indicative of an inductive or host-mediated response.

Tumor budding is a prognostic marker for overall survival and not for lymph node metastasis in Oral Squamous Cell Carcinoma - Systematic Review Update and Meta-Analysis.

Objective: Tumor budding (TB) has shown promising results as a prognostic marker in several cancers such as colorectal carcinoma, breast carcinoma etc. It has been co-related to aggressiveness of the tumor and can also predict the metastasis to the lymph nodes. This systematic review evaluates the prognostic potential of TB in predicting lymph node metastasis (LNM) in OSCC. Data sources: Systematic search was carried out in the electronic data-bases i.e. PubMed, Cochrane and Google scholar for original studies related to TB in OSCC. The assessment of risk bias was done using QUIPS tool. Meta-analysis was done using STATA software. Results: A total of 25 articles were included. A significant association was noted for overall survival and prognosis but not for TB LNM in OSCC. Meta-analysis revealed a pooled estimate i.e odds ratio of 2.10 (CI - 0.00 - 4.20) for TB and LNM while for overall survival, it was 2.29 (CI-1.81-2.76). Conclusion: Tumor budding though is strongly associated with LNM in OSCC did not show significant relationship in this systematic review but demonstrated a higher correlation with overall survival. It highlights that TB is an important parameter for prognosis of oral cancer but its potential in prediction of LNM needs further validation.

Enhanced ZEB 1 stromal expression is a marker for epithelial mesenchymal transition in oral submucous fibrosis.

Introduction: Oral submucous fibrosis is a progressive oral mucosal condition that is characterized by inflammation and persistent fibrosis. Epithelial Mesenchymal Transition is a crucial molecular event that contributes to tumor progression and fibrosis, with ZEB 1 and its effect on E-cadherin expression being key molecules in the process. Thera are no tissue level studies of these molecules in oral submucous fibrosis. Objective: To evaluate the immunohistochemical expression of epithelial mesenchymal transition markers E-cadherin and ZEB1 in oral submucous fibrosis. Methodology: A total of 30 cases of Oral submucous fibrosis (15 Early OSMF and 15 Advanced OSMF) classified based on the histopathological features were included in the study. Immunohistochemistry was done using two markers i.e. E-cadherin and ZEB1. The difference in the expression of E-Cadherin and ZEB1 among histo-pathological grades of OSMF was done by Mann-Whitney U test. Results: A slight reduction in the E-cadherin expression was noted in Oral submucous fibrosis but marked enhanced expression of ZEB1 was seen in the connective tissue of OSMF. Conclusion: An increase in intensity and percentage of positivity of ZEB 1 expression in connective tissue was observed in advanced cases as compared to early OSMF. This can be attributed to role of ZEB1 in mediating EMT via transdifferentiation of fibroblast into myofibroblast and thus predispose to fibrosis in OSMF.

Fine needle aspiration cytology for two cases of ameloblastoma-Key highlights and diagnostic features.

OBJECTIVE: Fine needle aspiration cytology (FNAC) is a valuable, noninvasive technique for head and neck pathology diagnosis. The objective of case images was to highlight the utility of FNAC for diagnosing suspected cases of ameloblastoma. METHOD: FNAC smears of suspected cases of ameloblastoma were evaluated using their cellular and stromal features. RESULTS: Cellular features and background of smears exhibited characteristics of ameloblastoma. Predominant features included clusters of ameloblast-like cells and spindle cells in a myxoid background. CONCLUSION: Careful evaluation of FNAC helps diagnose ameloblastomas and must be considered a vital diagnostic tool.

Role of cancer-associated fibroblasts in oral squamous cell carcinomas, surgical margins, and verrucous carcinomas: An immunohistochemical study.

Background and Aim: Cancer-associated fibroblasts (CAFs) are among the key tumor microenvironment components that determine tumor invasion, progression, and resistance to cancer therapeutics. Histologically normal mucosa adjacent to oral squamous cell carcinoma (OSCC) has been shown to harbor CAFs which aid in the loco-regional recurrence of the lesion. Verrucous carcinoma (VC), a low-grade variant of squamous cell carcinoma, has a better clinical outcome. However, few VCs show an aggressive biological course and necessitate wide excision with strict follow-up. Scarce literature is available regarding the role of CAFs in VCs. Thus, our study aimed to evaluate the frequency of CAFs in OSCC, normal mucosa adjacent to OSCC, and VC. Methods: Thirty cases of squamous cell carcinoma, normal mucosa adjacent to OSCC, and VC each were included in the study. The sections were stained with an antibody against alpha-smooth muscle actin protein and CAF frequency was evaluated. Results: The CAF frequency was highest in squamous cell carcinoma, followed by VC, and least in normal mucosa adjacent to OSCC (P<0.001). Conclusion: CAF frequency progressively increases with an increase in the grade or biological behavior of the lesion. Thus, screening CAF frequency in these benign and malignant oral lesions is necessary for better treatment outcomes. Relevance for Patients: The immunohistochemical screening for CAFs in OSCC and VC can serve as an integrated approach for the development of a directed treatment plan that leads to a better patient prognosis. Routine assessment of CAF frequency in surgical margins can serve as an adjunct in determining clear margins and possible locoregional recurrence. Furthermore, target therapy for CAFs can be used to minimize possible recurrence and distant metastasis.

Role of immunoreactive patterns of lymph nodes in neck dissection cases of oral squamous cell carcinoma: a clinical and histopathological study.

OBJECTIVES: Metastasis in oral squamous cell carcinoma (OSCC) can occur in a variety of ways, and draining lymphatics and lymph nodes serve as a common route. Prior to metastasis, lymph nodes elicit an immune response to either wall off or create a favorable environment for homing of tumor cells. This immune response to tumor stimuli is visualized by recognizing various immunoreactive patterns exhibited by the lymph node. The present study aims to evaluate the role of immuno-morphologic patterns of the lymph node in neck dissection for cases of OSCC. MATERIALS AND METHODS: Our retrospective study included 50 neck dissection cases of OSCC and a total of 1,078 lymph nodes. The grades of primary tumors with eight different immunoreactive patterns were compared. Vascularity and metastasis in lymph nodes were also evaluated. RESULTS: The lymphocyte predominant pattern was the most common immunoreactive pattern found in 396 of 1,078 lymph nodes. Patterns of lymphocyte predominant (P=0.0005), sinus histiocytosis (P=0.0500), paracortical hyperplasia (P=0.0001), cortical hyperplasia (P=0.0001), and increased vascularity (P=0.0190) were significantly associated with tumor grade. CONCLUSION: The present study adds to the understanding of lymph node immunoreactivity patterns and their correlation with tumor grade. We recommend further study of lymph node patterns for all sentinel lymph node biopsies and routine neck dissections for OSCCs.

Assessment of morphological parameters associated with neural invasion in oral squamous cell carcinoma.

AIMS: Neural invasion (NI) is a form of tumor spread distinct from lymphatic and vascular invasion. It has been correlated with aggressive behavior, disease recurrence and increased morbidity and mortality. Despite the importance of NI as a prognostic indicator, the mechanism and associated factors are poorly understood. Hence, the aim of this study was to determine morphological parameters associated with NI in oral squamous cell carcinoma (OSCC). METHODOLOGY: One hundred and five archival specimens of patients with primary OSCC who underwent surgical excision and radical neck dissection were included in the study. The presence of NI was analyzed in slides and correlated with clinical as well as morphological parameters using univariate and multivariate analysis. RESULTS: NI was identified in 31 cases (29%) of OSCC. NI was significantly associated with tobacco habit, lymphovascular invasion and positive surgical margins. Multivariate analysis further emphasized these factors to be significant risk factors for NI. Peri-NI and intra-NI significantly associated with the size of the tumor, while the distance of invasion was associated with advanced stage. CONCLUSION: NI is associated with multiple morphological parameters and its identification may have a significant impact on the management and prognostic evaluation of OSCC.

Tumor budding is a potential histopathological marker in the prognosis of oral squamous cell carcinoma: Current status and future prospects.

Tumor budding (TB) is a histopathologically evident feature that represents a scattered pattern of invasion consisting of isolated single tumor epithelial cells or tumor cells in small clusters (up to 5 cells) seen primarily at the invasive front dispersed within the stroma for variable distance. Presence of TB has been linked with lymph node metastasis, recurrence, distant metastasis and reduced survival in numerous cancers including oral squamous cell carcinoma (OSCC). Tumor buds are also considered as histopathological markers of epithelial-mesenchymal transition which is a molecular process implicated as a hallmark for invasion and metastasis. This review gives an overview of the current evidence regarding TB assessment in OSCC and its future prospects.

Assessment of cell block technique in head and neck pathology diagnoses: A preliminary study.

OBJECTIVE: The head and neck region is a composite site made of multiple tissue components. These tissues when affected by disease or pathology present with an array of changes in the tissue architecture and pattern. It is essential to visualize the cellular details and tissue patterns for accurate diagnosis and treatment planning. Aspiration cytology primarily makes use of the cellular details for diagnosing lesions of the head and neck. Despite the promising results, its use is still limited in certain cases of the head and neck. The reason implicated could be the indiscernible appearance of cells in the absence of tissue integrity. In this regard, cell blocks are known to facilitate the visualization of the cytomorphological as well as the tissue arrangement patterns. Thus, the present study was designed to evaluate the role of cell block cytology in the diagnosis of various lesions of the head and neck. METHODS: Odontogenic lesions, epithelial carcinomas and connective tissue pathology of the head and neck origin were included in the study (n = 45). Aspiration cytology smears and cell block diagnosis were compared with tissue biopsy diagnosis for determining their sensitivity (%) and diagnostic efficacy. RESULTS: Cell blocks showed distinct preservation of the architectural pattern. In case of fluid-filled lesions, the contents were preserved and correlated with the tissue biopsy results. The results of cell blocks were similar to that of tissue biopsy in majority of the cases (95.56%). CONCLUSION: We recommend using cell blocks as a part of routine laboratory practice for all head-neck cases.

Modified Alcohol-Formalin Cell Block Technique in Head and Neck Pathology Diagnosis.

OBJECTIVES: Cell block preparation is a recognized technique in histopathological diagnosis. This technique aids in maintaining an intact architecture and reducing the diagnostic errors associated with fine-needle aspiration cytology. Numerous techniques have been put forth, but the need for an optimal technique for routine use in the laboratory still persists. The aim of our study was to establish a cell block technique which aids in the accurate diagnosis of head and neck pathology. METHODOLOGY: A modified cell block technique was developed using alcohol-formalin as a fixative. Forty fine-needle aspiration fluids from clinically and radiologically diagnosed cases of head and neck pathology were used as samples. The cell block sections were compared with the cytology smears to determine the utility of the technique. RESULTS: The cell blocks presented with better preservation of the architectural framework and enabled a quick diagnosis. Cellular clumping was negligible, and nuclear as well as cellular details were maintained similar to tissue sections. It led to the integration of conventional techniques using 10% neutral buffered formalin with that of the 10% alcohol-formalin technique. CONCLUSION: Modified cell block technique can be used as a simple and effective tool in the routine diagnosis of head and neck pathology.

Evaluation of paxillin expression in patients with oral squamous cell carcinoma: An immunohistochemical study.

BACKGROUND: Oral squamous cell carcinoma (OSCC) is the tenth most common cancer in the world. The diagnosis of OSCC remains problematic, especially in advanced-stage tumors. AIMS: The present study was conducted to understand the pattern of expression of paxillin in varying grades of carcinomas and also to ascertain whether its expression has an association with increasing grades. METHODS: A total of ninety formalin-fixed paraffin-embedded tissues of OSCC were included in the study comprising thirty cases of each of well-differentiated squamous cell carcinomas, moderately differentiated squamous cell carcinomas (MDSCCs) and poorly differentiated squamous cell carcinomas (PDSCCs). The tissue sections were subjected to immunohistochemical staining of paxillin using super polymer-sensitive polymer 3,3' diaminobenzidine detection kit. All the three groups were analyzed on various parameters including staining intensity, location and percentage of staining. SPSS 19.0 was used to analyze the data. RESULTS: Paxillin stain positivity was observed in 95.5% of the cases. Predominant intense paxillin staining was demonstrated in 17 (56.6%) cases of well-differentiated squamous cell carcinoma, 28 (93.3%) cases of moderately differentiated squamous squamous cell carcinoma and 15 (50%) cases of PDSCC. A predominant cytoplasmic staining was observed in 21 (70%) cases of PDSCC and cytoplasmic plus membrane staining in 14 (46.6%) cases of MDSCC. CONCLUSION: The present study provides evidence that paxillin may be involved in the development and progression of OSCC. Thus, paxillin could be considered a useful biomarker for patient management and prognosis.

Immunoexpression of Epithelial Mesenchymal Transition Proteins E-Cadherin, ß-Catenin, and N-Cadherin in Oral Squamous Cell Carcinoma.

Aims Epithelial mesenchymal transition (EMT) is a crucial process for acquisition of malignant phenotype, aggressiveness, and metastatic capacity in neoplasms. It is characterized by loss of epithelial markers and gain of mesenchymal markers. Studies on EMT and its potential association with the histological grading are sparse in oral squamous cell carcinoma (OSCC). This study aims to evaluate the expression of EMT-associated proteins-E-cadherin, ß-catenin, and N-cadherin-in different grades of OSCC. Methodology In all, 60 cases of OSCC further subdivided into 20 cases each of well-, moderately, and poorly differentiated OSCCs were stained immunohistochemically with E-cadherin, ß-catenin, and N-cadherin antibodies. The differences in the expression were evaluated using χ2 and Fisher exact tests, whereas Spearman's correlation was used to analyze the correlation between the markers. Results A reduced E-cadherin expression noted in 40% of the OSCCs was associated with reduced ß-catenin expression in 66.6% of the cases and increase in the expression of mesenchymal N-cadherin seen in 80% of cases. This expression pattern demonstrated a significant association with histological grades. A membrane to cytoplasmic shift of E-cadherin (73.3%) and ß-catenin (78.3%) increased with histological grade. A negative correlation was observed with the E-cadherin and N-cadherin localization, though it did not reach statistical significance. Conclusion OSCC tissues had high levels of EMT phenotype as compared with the normal oral mucosa. This phenotype was characterized by reduced E-cadherin and ß-catenin expression and overexpression of N-cadherin. Aberrant localization of the studied proteins was a hallmark for depicting EMT.

Diagnoses of 964 oral biopsies from people aged over 50 years in Karnataka State, India.

INTRODUCTION: The drastic epidemiological transition has created a huge void in evidence with regard to the health statistics of elderly population. Data are sparse on the oral mucosal conditions prevalent among the elderly Indian population. This study aimed to review the oral biopsies reported in the institute over the last 21 years and to examine the trends in geriatric oral pathologies. METHODOLOGY: A total of 964 histologically confirmed geriatric (age ranging 50-97 years) oral lesions among 4000 cases reported were retrieved from the files of Department of Oral Pathology and Microbiology of KLE VK institute, Belgaum, Karnataka commencing since 1992 till 2012. These cases were retrospectively evaluated for various parameters such as age, gender, duration, location and type of lesions. RESULTS: The geriatric oral lesions were seen to occur predominantly in men (65%), especially the sixth decade of life (47%). The most common location was the buccal mucosa (29%). The malignant neoplastic lesions accounted for the majority of the geriatric lesions (36%) followed by non-neoplastic lesions (27%), potentially malignant disorders (26%) and benign neoplasms, which formed a minor proportion of (11%). The oral squamous cell carcinoma was the single most common geriatric lesion accounted. Gender and age-wise correlation analyses among the various lesion categories showed statistical significance. CONCLUSION: The study provides valuable information about major oral pathologies in our scenario that contribute to significant morbidity and mortality among the geriatric population. It also sheds light about the diseases that need to be targeted in future Indian public health policies and initiatives for geriatric care.

GLUT-1 immunoexpression in oral epithelial dysplasia, oral squamous cell carcinoma, and verrucous carcinoma.

Glucose transporters, such as GLUT-1, mediate the important mechanisms involved in cellular glucose influx, allowing cells to proliferate and survive. The significance of GLUT-1 expression in oral epithelial dysplasia (OED) and oral squamous cell carcinoma (OSCC) has been less explored, and no study has investigated it in relation to verrucous carcinoma (VC). We evaluated 30 cases each of OED, OSCC, and VC, graded further on the basis of their differentiation, immunohistochemically for GLUT-1 expression, along with 10 specimens of normal oral mucosa (NOM) as controls. In OSCC, GLUT-1 expression increased with the degree of dysplasia and increasing grade (P < 0.001). The expression in VC was predominantly membranous and intense, resembling well differentiated OSCC. This increase of GLUT-1 expression in OSCC along with the degree of dysplasia and the histologic grade reflects the expanding glycolytic response to hypoxia. This is the first study to have revealed prominent GLUT-1 expression in VC, highlighting its inherent metabolic capacity.

Pentoxifylline in patients with oral submucous fibrosis-a randomized clinical trial.

BACKGROUND AND AIM: As far as research regarding any disease is concerned, each and every aspect poses a challenge. One such entity that poses a challenge in our arena is oral submucous fibrosis (OSF) as no effective treatment is available for this progressively disabling condition with high malignant potential. Hence the present study was undertaken with the aim to determine the use of pentoxifylline (PTX) on the clinical and histopathologic course of OSF. METHOD: Thirty clinically confirmed OSF patients were categorized randomly into group I and group II. In group I, drug PTX was administered as an adjunct along with other conventional therapies. Group II patients were advised conventional therapies only. Pre- and post-treatment biopsies were obtained for the following parameters:Micro-vascular density (MVD),Area percentage of blood vessels,Severity of fibrosis, andInflammatory components. RESULTS:  On comparing MVD in groups I and II there was no significant difference in pre- and post-treatment.On comparing the average area percentage occupied by blood vessels, significant difference was seen in pre- and post-treatment biopsies in group I.On assessment of mouth opening and tongue protrusion, there was no significant improvement in either of the groups individually or in comparison. But when burning sensation of mucosa was assessed, pre- and post-treatment, both groups showed quite significant improvement individually. CONCLUSION: Use of pentoxifylline seemed to be questionable, and taking into consideration the long administration time, its use is not recommended for the treatment of OSF patients.

Tumor budding is an independent prognostic factor for prediction of lymph node metastasis in oral squamous cell carcinoma.

OBJECTIVE: Despite the enormous advances in diagnostic and management modalities of oral squamous cell carcinoma (OSCC), the mortality rates have remained stagnant with a 5-year survival rate of <50% challenging the available methods of prognostic assessment. Presence of tumor budding has been associated with aggressive behavior and is correlated with lymph node metastasis, recurrence, distant metastasis, and decreased survival in several cancers. However, the prognostic significance of this apparently simple to evaluate parameter is sparse in OSCC. METHODS: A total of 75 cases of surgically excised OSCC were analyzed for tumor budding along with other clinicopathologic parameters. Tumor budding was graded as high and low intensity based on presence and absence of ≥10 or <10 budding foci in hematoxylin and eosin-stained sections. An association between the clinicopathological parameters, lymph node metastases with the budding index was examined using univariate and multivariate analyses. RESULTS: Tumor budding was evident in 89% of cases with around 45.3% of the cases demonstrated high-intensity budding. High-intensity tumor budding was significantly associated with lymph node metastasis and depth of invasion. Multivariate analysis demonstrated that tumor budding and depth of invasion were significant independent predictors for lymph node metastasis. CONCLUSION: Tumor budding is frequently encountered histologic marker in OSCC. High-intensity tumor budding is a strong independent prognostic factor for prediction of lymph node metastasis.

Morphometric analysis of the mucosal vasculature in oral submucous fibrosis and its comparison with oral squamous cell carcinoma.

Oral submucous fibrosis (OSMF) is a chronic fibrotic disorder in which the degree of vascularity has always been a matter of dispute; however, morphological studies of the blood vessels in OSMF have been sparse. This study was performed to assess the mucosal vasculature in normal oral mucosa, early and advanced OSMF, and well differentiated squamous cell carcinoma (WDSCC) using morphometry. The study included histologically diagnosed cases of early (n = 30) and advanced (n = 30) OSMF, and WDSCC (n = 30), with normal oral mucosa (n = 10) as a control. Morphometric image analysis of blood vessels was performed on H&E-stained sections for evaluation of vascular density, vascular luminal diameter, area and percentage area. A significant increase in all of the parameters was noted in the test groups relative to the controls. The mean vascular density and mean vascular percentage area were significantly increased in early OSMF and WDSCC relative to controls, and also in advanced OSMF and WDSCC in comparison with early OSMF. The vascularity increased progressively from normal to premalignancy and malignancy, emphasizing the importance of angiogenesis in tumor development and progression. The vascularity was increased in early OSMF and reduced in advanced OSMF, suggesting that inflammation may play a role in the early stages while progressive fibrosis may predispose to atrophy of the epithelium and subsequent malignant changes.

Quantitative and qualitative analysis of epidermal growth factor receptor expression in pericoronal follicles in predicting proliferative potential.

OBJECTIVE: The odontogenic epithelium in pericoronal follicles (PFs) are known to proliferate to form cysts and tumors. This epithelium is mostly composed of the reduced enamel epithelium (REE) and odontogenic rests (OR). The objective of the present study was to evaluate the epidermal growth factor receptor (EGFR) immunoexpression in these PFs to assess their proliferative potential. STUDY DESIGN: The immunoexpression of EGFR in 30 PFs were assessed by two independent observers for intensity, percentage and the location of the EGFR staining. RESULTS: EGFR immunoexpression was noted in 100% of the follicles. A greater proportion of the follicles showed strong intensity (70%). It was noted that nearly 54% of the follicles demonstrated more than 50% of cells with EGFR immunolabelling. EGFR showed combined cytoplasm and membrane staining (40%) and cytoplasm only staining (37%). The analysis of the REE and OR individually for the above-mentioned parameters did not show statistical significance. CONCLUSION: The increased intensity and overall positivity of the epithelium in follicles shows that odontogenic epithelium is responsive to EGFR mediated growth factors. The predominant combined staining pattern is suggestive of increased potential for the epithelium to undergo cystic or neoplastic proliferation.