Vascular endothelial growth factor (VEGF) expression in oral tissues: possible relevance to angiogenesis, tumour progression and field cancerisation.

The aim of this study was to assess whether vascular endothelial growth factor (VEGF) expression in oral tissues is associated with angiogenesis, disease progression or field cancerisation. Vascularity and VEGF immunoreactivity were quantified in 68 archival specimens including normal oral mucosa (NOM), dysplasia (DYS) and squamous cell carcinoma (SCC). Vascularity increased significantly with disease progression; it was also higher in NOM adjacent to SCC than in NOM from healthy tissue, suggesting an association with field cancerisation. VEGF expression in epithelial cells was evaluated using two antibodies and three indices. VEGF indices and vascularity were not directly correlated. The expression of VEGF was similar in all DYS and NOM specimens, whether or not adjacent to a concurrent lesion. A comparison of SCC with NOM or DYS led to opposite results, depending on the VEGF antibody and index used. We conclude that VEGF expression in the oral mucosa may play a physiological role, but does not appear to be associated with angiogenesis, field cancerisation or transition to dysplasia. Further studies concerned with tumour development require examining specific VEGF isoforms and standardisation of the methodology.

Apoptosis, proliferation, and angiogenesis in oral tissues. Possible relevance to tumour progression.

Experimental animal models have demonstrated that angiogenesis is essential for tumour progression, whilst sustained tumour growth requires a positive balance between tumour cell proliferation and cell death (apoptosis). The aim of this study was to determine the relative contribution of apoptosis, proliferation, and angiogenesis to disease progression in the oral mucosa. Histological sections of 47 archival specimens were examined; these included four groups of oral tissues: normal mucosa (n=12), moderate dysplasia (n=11) severe dysplasia (n=6), and squamous cell carcinoma (n=18). Apoptotic cells were visualized by in-situ end-labelling of DNA, proliferative cells by staining with Ki-67 antibody, and blood vessels with von Willebrand factor (vWF) antibody. One-way analysis of variance showed that indices of apoptosis (AI), proliferation (PI), and angiogenesis (vascularity) increased significantly with disease progression from normal oral mucosa, through dysplasia, to carcinoma (p<0.0001 for every index). The increase from normal mucosa to moderate dysplasia was significant for PI and vascularity, but not for AI. In contrast, the increase from dysplasia to carcinoma was significant for AI and vascularity, but not for PI. These data suggest that disease progression in the oral mucosa is accompanied by angiogenesis and increases in both epithelial proliferation and apoptosis. Net epithelial growth results from proliferation starting earlier and proceeding at a higher rate than apoptosis.

The presence of pericytes and transitional cells in the vasculature of the human dental pulp: an ultrastructural study.

The aim of this study was to determine the ultrastructural characteristics of the microvasculature of healthy human dental pulp, with particular reference to pericytes. Pulp tissue was taken from healthy impacted third molars following extraction. Eight teeth were obtained from 17- to 25-year-old patients and pulp tissue was processed for examination using standard techniques for transmission electron microscopy. The pulp was rich in capillaries composed of endothelial and peri-endothelial cells in a 4: 1 ratio. Endothelial cells contained typical and abundant Weibel-Palade bodies. Three types of peri-endothelial cells were identified: pericytes, transitional cells and fibroblasts. Pericytes were embedded within the capillary basement membrane. Transitional cells were partly surrounded by basement membrane, but separated from the endothelium by collagen fibrils; fibroblasts were outside, but adjacent to the basement membrane and closely associated with collagen fibrils. Pericytes and transitional cells, but not peri-endothelial fibroblasts, contained low numbers of dense bodies similar to the endothelial Weibel-Palade bodies. Our observations are consistent with the hypothesis that, during normal tissue turnover, some pericytes may originate from endothelium and migrate away from the vessel wall to undergo transition to a fibroblastic phenotype.

Angiogenesis and vasodilation in skin warts. Association with HPV infection.

BACKGROUND: Angiogenesis is required for tumour growth. Since human papillomavirus (HPV) infection is associated with the development of neoplastic lesions, the aim of this study was to determine the possible association between HPV infection and angiogenesis in benign tumours. MATERIALS AND METHODS: Specimens of skin warts which were either negative for HPV types 1, 2, 3 and 4 (HPV-ve; n = 15), or positive for HPV2 (HPV+ve; n = 19) were compared with normal skin (NS, n = 10). Vascularity and inflammation were assessed in consecutive sections. vWF-positive blood vessels were classified as small or large using a cut-off value of 50 microns diameter. RESULTS: Vascularity values for small vessels increased significantly from NS to HPV-ve warts and from HPV-ve to HPV+ve warts. Large vessels were found only in warts and their abundance was not related to HPV status. No significant association was found between vascularity and inflammation or between vascularity values for small and large vessels. CONCLUSIONS: The development of skin warts is accompanied by angiogenesis and vasodilation and these two processes may be independently regulated. Further increased angiogenesis, but not vasodilation, is associated with the presence of HPV type 2 DNA.

Plasma cell mucositis: a review and case report.

The simultaneous involvement of the mucous membranes of the oral cavity and upper aerodigestive tract by lesions characterised clinically by an intensely erythematous, lobulated surface and histologically by a dense connective tissue infiltrate composed of non-neoplastic plasma cells may be called plasma cell mucositis. We present a review of the literature, consisting of 14 cases, outlining the multifocal site distribution, chronicity and systemic background that distinguish this entity and report a single case with confirmation of the polyclonal nature of the plasma cell infiltrate using gene rearrangement studies.

The association between epithelial proliferation and disease progression in the oral mucosa.

The purpose of this study was to examine the possible association between epithelial proliferation and disease progression in the oral mucosa. Archival specimens of normal oral mucosa (n = 12), dysplasia (n = 17) and squamous cell carcinoma (n = 18) were sectioned and proliferating cells visualised by staining with Ki-67 antibody. The proliferative index of the epithelium (PI) was determined by total cell counts and point counting. Similar results were obtained using either method. Comparison of the three groups of tissues by one-way analysis of variance showed a significant increase in PI with increasing lesion severity (p < 0.001). The PI of both dysplasia and carcinoma groups was significantly higher than that of normal oral mucosa (p < 0.001). However, the difference between dysplasia and carcinoma groups was not significant. PI was not associated with tobacco or alcohol consumption. We therefore conclude that Ki-67 expression is an early marker of disease progression in the oral mucosa but, on its own, is not a good indicator of neoplastic transformation.

Relationships between different measurements of vascularity and clinico-pathological parameters in breast cancer.

Microvascular density has been put forward as an independent prognostic factor in breast cancer, with high levels indicating poorer prognosis. However, various studies have failed to confirm its prognostic value. The reasons for the contradictory results are not known, but it is believed that methodological differences are responsible. To test this hypothesis, we have used four different methods of assessing vascularity (average and highest microvascular density, microvascular volume and image analysis of vascular area) and related them to known prognostic factors in 51 cases of breast cancer NOS. All four methods showed a significant correlation with each other, with the exception of image analysis vs microvascular volume. The average microvascular density was significantly lower in p53 positive compared to negative tumours (median 38.4 and 66.2; IQR 31.1 and 49.4, respectively, p < 0.05). Vascularity, measured by the four methods, was not associated with nodal status or any other parameter examined.

Assessment of vascularity in histological sections: effects of methodology and value as an index of angiogenesis in breast tumours.

The aims of this study were to (a) determine how the quantification of blood vessels in histological sections (vascularity) is affected by the methodology used and (b) assess the value of vascularity as an index of angiogenesis by comparing tumour and normal breast tissue. Archival specimens of breast, lung and oral carcinoma, oral dysplasia and normal breast tissue were used to test the effects of the following experimental variables on vascularity: pretreatment of the sections (enzymatic digestion, heating), endothelial markers (von Willebrand factor and CD31 antibodies), method of quantification (highest microvascular density, average microvascular density and microvascular volume) and interobserver variations. All the variables examined significantly affected the estimated vascularity; this depended on the type of tissue and method used. The pretreatment of the sections before staining was the most important variable, altering the vascularity ranking of the tumours. Vascularity in breast tumours was similar to that of the normal breast intralobular stroma, suggesting that an area of high microvascular density in the tumour does not necessarily represent tumour-induced angiogenesis. Contradictory results have been published regarding the value of vascularity as a tumour prognostic factor. Our results suggest that statistically significant differences in vascularity values are most likely to arise from failure to optimize the staining protocol and from the method used to assess vascularity.

The association between tumour progression and vascularity in the oral mucosa.

Tumourigenesis in experimental models is associated with the formation of new blood vessels (angiogenesis). Recent studies have suggested that tumour angiogenic activity may be inferred in histological sections by measuring the density of the vasculature. The purpose of this study was to determine whether the transition from normal to dysplastic and neoplastic tissue in the oral mucosa is accompanied by quantitative or qualitative changes in the vascularity of the tissue, and how the estimate of vascularity is influenced by the vessel marker and method of assessment. A total of 100 specimens of normal oral mucosa, dysplastic lesions, and squamous cell carcinomas were examined. Sections were immunostained with the pan-endothelial antibodies to von Willebrand Factor (vWF) and CD31, or with an antibody to the alpha v beta 3 integrin, previously reported to be a marker of angiogenic vessels. Vascularity was quantitated by two different methods: highest microvascular density (h-MVD) and microvascular volume, as determined by point counting (MVV). The results showed that vascularity, measured by the MVV method using antibodies to either vWF or CD31, increased significantly (P < 0.0001) with disease progression from normal oral mucosa, through mild, moderate, and severe dysplasia to early and late carcinoma (76 paraffin-embedded tissues examined). In contrast, h-MVD did not discriminate between dysplastic lesions and carcinoma. A similar percentage of the total vessel volume (MVV) and density (h-MVD) were positive for alpha v beta 3 in 24 frozen tissues examined, including normal oral mucosa. It is concluded that there is a close association between vascularity and tumour progression in the oral mucosa. Morphometric analysis reflecting microvascular volume is more informative than the currently popular analysis of microvascular density. The expression of alpha v beta 3 in the vasculature of oral tissues does not necessarily reflect the presence of angiogenic vessels.

Overexpression of p53 in normal oral mucosa of oral cancer patients does not necessarily predict further malignant disease.

Recent reports of p53 positivity in the normal mucosa of some head and neck cancer patients have been taken as evidence for field cancerization and hence a likelihood of the development of further tumours, yet few papers report the clinical significance of this finding through long-term follow-up. The immunohistochemical detection of p53 expression in clinically and histopathologically normal oral mucosa taken from the wound margin following excision of oral cancer was assessed using the polyclonal antibody CM1. Fresh frozen biopsies of normal oral mucosa and the corresponding tumour from 21 oral cancer patients and of normal mucosa from 25 non-cancer patients were assessed for p53 overexpression. The 'normal' mucosa was positive in 12 of the oral cancer patients and one of the non-cancer patients. Second malignant tumours were seen in patients from whom p53-positive 'normals' and p53-negative 'normals' were recorded. In five of the p53-positive 'normals', the corresponding cancer was p53-negative. In one case, where 'normal' mucosa was available from more than one site, one region was positive, whilst the other was negative. No obvious difference in age, tobacco use, or recurrence rate was seen between positive and negative cases. All patients who were still alive were reviewed for a minimum of 5 years. Using Fisher's exact test, no statistically significant difference was found for the rate of second malignant tumours occurring in patients with p53-positive compared with p53-negative normal mucosa. Thus, the detection of p53 in normal mucosa did not necessarily predict a further tumour.

Relationship between vascularity, age and survival in non-small-cell lung cancer.

Lung tumours in the elderly show reduced growth potential; impaired angiogenesis may contribute to this phenomenon. Recent studies have suggested that the angiogenic potential of a tumour may be inferred by the vascularity measured in histological sections. The purpose of this study has been to determine whether vascularity is related to age, survival or other clinical parameters in resected non-small-cell lung cancer (NSCLC). A group of 88 consecutive patients with a follow-up period of at least 5 years was selected. The group exhibited a wide age range (37-78 years) and similar survival characteristics to those of the general NSCLC population. Tumour sections were stained with a pan-endothelial antibody (vWF) and vascularity was quantitated, without knowledge of the clinical details, by three methods: highest microvascular density; average microvascular density; and average microvascular volume. The results were analysed by non-parametric statistical tests. A correlation was found between all three methods of quantitation. Vascularity was not associated with age, sex, tumour type, stage, volume, size (TNM-T) nodal status (TNM-N) or survival. However, survival time was generally longer for patients with higher vascularity, reaching borderline significance (P = 0.06) for the average microvascular density values. Higher tumour volume (P = 0.02) and stage (P = 0.05) were associated with lower survival times. Using multivariate survival analysis, tumour volume was the only factor related to survival. We conclude that vascularity is not associated with age and has no significant prognostic value in NSCLC.

The utility of cytokeratin profiles for detecting oral cancer using exfoliative cytology.

It is generally agreed that there is a need for a routine, non-invasive screening procedure for oral cancer particularly of high risk groups. Refinements in oral exfoliative cytology now make this technique worthy of consideration for such screening. This study assesses the utility of monitoring cytokeratin expression in smears of oral cancer in comparison with assessing the keratin expression in corresponding biopsies. Smears and biopsies were taken from 34 patients with oral cancer. A panel of antibodies, CAM5.2, LH1, AE8, LP2K and LH8 recognising keratins 8, 10, 13, 19 and a basal cell marker respectively were employed. Keratins were identified using a standard immunocytochemical technique (Vectastain) and assessed on a 3 point scale, for both smears and biopsies. The vast majority of tumours were well differentiated. No particular keratin profile scen within the smear was associated with any particular state of differentiation. Although the sensitivity of K19 was greatest, its specificity was poor. The keratin antibodies with the best positive predictive value were CAM5.2 (K8) and the marker of the basal cell phenotype, LH8. The combination of down regulation of the secondary differentiation markers (K13, K10) coupled with 'simple' keratin expression (K8, K19) would seem to be the most consistent profile. We conclude that for exfoliative cytological screening to be of value as a diagnostic test it remains necessary to employ assays using more than one antikeratin antibody.

Exfoliative cytology of normal oral mucosa. Assessing the basal cell keratin phenotype.

OBJECTIVE: To attempt to evaluate the likelihood that normal keratin (antibody LH8) expression might contribute to a false positive diagnosis when sampling a lesion affecting the oral mucosa. STUDY DESIGN: Smears were taken from four oral sites (buccal mucosa, hard palate, dorsal tongue, ventral tongue) in 28 patients using the Axibrush. These were processed using a standard avidin-biotin technique, and the number of brown "positive" cells was assessed. RESULTS: None of the smears contained cells that were LH8 positive. CONCLUSION: While the results of this study suggest that exfoliative cytology is poor at sampling the basal cells of intact oral epithelium, it does indicate that the identification of LH8-positive cells in a smear from a clinically suspicious lesion is unlikely to be due to harvesting of normal basal cells.

Subpopulations of fetal-like gingival fibroblasts: characterisation and potential significance for wound healing and the progression of periodontal disease.

Wound healing in the adult is commonly compromised by excessive scar formation. In contrast, fetal wound healing is a regenerative process characterised by the conspicuous absence of scarring. Available evidence suggests that phenotypic differences between fetal and adult fibroblasts are important determinants of these distinct modes of tissue repair. In this context, a number of groups (including our own) have documented differences between fetal and adult fibroblasts with respect to such potentially relevant characteristics as migratory activity, motogenic response to cytokines and the synthesis of motility factors, cytokines and matrix macromolecules. The oral mucosa appears to be a privileged site in the adult in that it continues to display a fetal-like mode of wound healing. Data are presented in this review indicating that a subpopulation of gingival fibroblasts expresses several 'fetal-like' phenotypic characteristics. These observations are discussed in terms of both the continued expression of a fetal-like mode of wound healing in the oral mucosa and the possible differential involvement of distinct fibroblast subpopulations in the progression of periodontal disease.

A histological, lectin and S-100 histochemical study of the developing prenatal human sublingual salivary gland.

Lectin and S-100 protein histochemistry during fetal growth and development (10-38th gestational weeks) of these glands was studied. The histological development of glandular structures followed the known pattern for other salivary glands. Using biotinylated lectins Ulex europeus-I, Dolichos biflorus, Glycine maximus (soyabean), Helix pomatia, Arachis hypogaea (peanut) and Triticum vulgare (wheatgerm), the binding level and, by implication, the concentration of associated specific oligosaccharide available for binding was low at 10 to 19 weeks and generally higher as maturity increased through the middle and late stages of development. S-100 protein reactivity was demonstrated in the cytoplasm of basophil acinar cells of the gland primordia from their origin. Stereological analysis of these developing salivary glands showed a highly significant progressive increase in proportional gland volume occupied by acini from 25% at 20 weeks to 60% at 38 weeks (p < 0.0001), and a comparable halving of the relative gland volume occupied by connective tissue in the same period (p < 0.0001). The extent of these changes depended upon the stage of differentiation and maturation of the glands but by the late stage of fetal development, histochemical reactions were similar to known adult patterns.

Cell proliferation and apoptosis in isoprenaline-induced sialosis in the rat submandibular glands.

Regression of submandibular acinar cell hyperplasia after withdrawal of the mitogenic stimulus induced by isoprenaline was studied in male Wistar rats. Intraperitoneal administration of 39 mg of isoprenaline, in divided doses over a 9-day period, resulted in a marked increase in gland size and weight. The proportional volume occupied by acinar cells increased. These changes were associated with acinar cell proliferation and an increase in the mitotic index and cytoplasmic: nuclear ratio. Thus, both hyperplasia and hypertrophy clearly contributed to gland enlargement. Granular and other duct cells appeared to be unaffected by isoprenaline administration. Following cessation of the drug, the mitotic index reached a peak value by the second day but thereafter declined rapidly. This change was matched by a marked rise in the apoptotic cell index, the latter reaching a maximum by the fourth day. By the end of the second week, glands had returned to normal with respect to size and weight and neither hyperplasia nor apoptosis could be detected histologically. These results confirm that apoptosis is involved in the regulation of submandibular salivary gland size.

Histochemical study of lectin binding in the human fetal minor salivary glands.

The emerging synthesis of glycoconjugates containing specific oligosaccharides in developing human fetal labial and lingual salivary glands has been investigated by lectin histochemistry. An avidin-biotin technique was used to study the binding of lectins from Ulex europeus I (UEA-I), Dolichos biflorus (DBA), Glycine maximus (SBA), Helix pomatia (HPA), Arachis hypogaea (PNA) and Triticum vulgare (WGA) to specific sugars on sections of tissue from labial glands, glands of Blandin and Nuhn, glands of von Ebner and the dorsoposterior lingual salivary glands. Incipient synthesis of glycoconjugates in early glands and their presence in the cells and ducts of the later glands was shown. The study also showed a time-related increase in both staining intensity and binding sites of serous acinar cells from all glands and for all lectins used. For mucous cells, peak intensity of staining was reached by the middle phase of development. During later gland development this intensity was maintained in dorsoposterior lingual glands but tended to decline in labial glands. The various lectins showed different degrees of binding but UEA-I lectin generally bound the L-fucose sugar group in all salivary glands at all gestational ages. The results showed that lectins appear to bind to the oligosaccharides on epithelial cell surfaces of fetal salivary glands at all stages of development. The degree of change depends upon the stage of differentiation and maturation of the glands.

Influence of temperature on long-term keratin immunoreactivity for oral exfoliative cytology.

We previously showed that keratin profiles can be of value in the diagnosis of oral cancer when using exfoliative cytology. In the future, they may form part of a screening program for oral cancer. This study evaluated the influence of long-term storage on keratin expression. Smears were collected from the clinically normal buccal mucosa and dorsal tongue of 22 patients. Half were stored in a refrigerator (5 degrees C) and half in a freezer (-70 degrees C). A total of 528 smears were collected. A panel of three antikeratin antibodies (LP34, AE8 and 1C7) was used to identify the preservation of keratin expression (graded as absent, few cells positive or many cells positive). The results for smears from dorsal tongue indicated that many cells were impermeable by the antikeratin antibodies. However, a satisfactory level of keratin immunoreactivity was observed in smears from buccal mucosa stored at -70 degrees C for over one year. Results for storage at 5 degrees C for both sites were inadequate after one month. Thus, smears from nonkeratinized oral sites may be stored at -70 degrees C for at least one year without a profound loss of keratin immunoreactivity, thus allowing examination of archival material.

Cell deletion by apoptosis during regression of rat parotid sialadenosis.

Enlargement of the rat parotid salivary glands was induced by repeated administration of isoproterenol. Mean wet weights of the treated glands increased steadily to 240% of control values. Following withdrawal of the drug, quantitative histological techniques were used to investigate the balance between hypertrophy, hyperplasia and apoptosis. The volume occupied by acinar cells relative to the total gland volume together with cytoplasmic magnitude of nuclear area ratios as measures of hypertrophy increased during the early experimental period. Similarly, serous acinar cell mitotic counts increased, indicating that hyperplasia had occurred. Apoptosis was demonstrated at light microscopical level to be the main mechanism for cell deletion as the glands returned to normal size and weight. The results indicate that hypertrophy and hyperplasia of serous acinar cells contribute to isoproterenol-induced sialadenosis. The experimental animal model demonstrates that these proliferative changes are completed by 48 h and thereafter are balanced by apoptosis as the glands recover their normal size and weight.

DNA and keratin analysis of oral exfoliative cytology in the detection of oral cancer.

Refinements in oral exfoliative cytology may make it a suitable screening technique for the early diagnosis of oral cancer. In this study DNA range profiles were combined with keratin expression in an attempt to improve the diagnostic accuracy of oral exfoliative cytology. Smears were taken from 33 biopsy-proven oral cancers and the contralateral normal site. For DNA range profiles the smears underwent Feulgen hydrolysis, with DNA distribution being assessed using the Vickers M85 microdensitometer. For keratin expression a panel of antikeratin antibodies were applied. The smears for keratin expression were then graded on a three-point scale. Abnormal DNA range profiles were observed in 23 of 33 smears taken from oral cancers and in two smears from normal oral mucosa (sensitivity 70%, specificity 90%, positive predictive value 90%). The simple epithelial keratins 8 and 19 were identified in the majority of oral cancer smears. The sensitivity of keratin 19 was greater (90%). However, keratin 8 was the most useful keratin marker associated with malignancy (sensitivity 62%, specificity 100%, positive predictive value 100%). The combination of simple keratin expression and DNA content improved the cancer detection rate beyond that obtainable with DNA range profile alone.