Can Superselective Intra-Arterial Chemoradiotherapy Replace Surgery Followed by Radiation for Advanced Cancer of the Tongue and Floor of the Mouth?

PURPOSE: The purpose of this study was to compare quality of life (QoL) and the survival rate after surgery with and without radiotherapy versus superselective intra-arterial chemoradiotherapy (SSIACRT) for advanced cancer of the tongue and floor of the mouth. MATERIALS AND METHODS: Patients with stage III and IV squamous cell carcinoma of the tongue and floor of the mouth treated between 2000 and 2013 were included in this study. The predictor variables were surgery without radiotherapy, surgery followed by radiotherapy, and SSIACRT. The outcome variables were QoL and the survival rate. The University of Washington QoL questionnaire (UW-QOL) was used for evaluation of QoL. The Kaplan-Meier method was used to estimate the overall survival rate. The UW-QOL was analyzed by analysis of covariance, and the survival rate was analyzed statistically by the log-rank test. RESULTS: Sixty-two patients were eligible for this study. Of these, 13 were treated by surgery without radiotherapy, 29 were treated by surgery plus radiotherapy, and 20 were treated by SSIACRT. The SSIACRT group had the best UW-QOL scores among the 3 groups. The 5-year Kaplan-Meier disease-specific survival rates for these groups were 92.9%, 62.9%, and 83.2%, respectively, with no significant difference (P = .20) shown. CONCLUSIONS: The QoL scores of the SSIACRT group were the best among the 3 groups in most domains. The superiority of QoL and the survival rate in the SSIACRT group showed that SSIACRT should be preferred in managing advanced cancer of the tongue and floor of the mouth.

Professional oral health care reduces oral mucositis pain in patients treated by superselective intra-arterial chemotherapy concurrent with radiotherapy for oral cancer.

PURPOSE: Oral mucositis (OM) is a painful complication of radiation therapy (RT) for head and neck cancer. OM can compromise nutrition, require opioid analgesics and hospitalization for pain control, and lead to interruption of treatment. Severe oral mucositis appears inevitable in superselective intra-arterial chemotherapy concurrent with radiotherapy (SSIACRT), requiring management of OM for the patient. The objective of this study was to assess the utility of professional oral health care (POHC) for the management of OM in patients undergoing SSIACRT. METHODS: Thirty-three patients were enrolled in this study. The first 17 patients underwent SSIACRT before we created an oral management team, and thus did not receive POHC. The remaining 16 patients received POHC. Fever duration, duration of oral feeding difficulty, opioid usage, duration of opioid administration, duration of hospitalization, and number of hospital days from the end of irradiation to discharge were compared between these two groups. RESULTS: Median total dose of morphine during SSIACRT, median number of hospital days from end of irradiation to discharge, and duration of hospitalization all differed significantly between groups (P < 0.05). Duration of opioid administration, fever duration, and duration of oral feeding difficulty did not differ significantly between groups. CONCLUSIONS: These findings indicate that POHC may reduce opioid use and shorten the hospital stay. Such results might be obtained through infection control by POHC. This report appears to be the first study to evaluate the efficiency of POHC in SSIACRT for oral cancer from the perspective of mucositis pain and opioid use.

Role of type I- and type II-interferon in expression of melanoma differentiation-associated gene-5 in HSC-3 oral squamous carcinoma cells.

Melanoma differentiation-associated gene 5 (MDA-5) and retinoic acid-inducible gene-I (RIG-I)are members of DExH family of proteins, and known to play important roles in antiviral responses to induce type I interferons (IFNs). MDA-5 has been thought to sense RNA virus with long(>1 kb) double-stranded RNA. However, MDA-5 is also induced by type II IFN that is involved in acquired immunity, suggesting that role of MDA-5 remains to be elucidated. In addition, no study regarding MDA-5 in oral region has been performed. Here we investigated the role of MDA-5 in HCS-3 squamous carcinoma cells derived from oral epithelial cells. Treatment of HCS-3 cells with IFN-α2b or IFN-γ significantly induced MDA-5 as well as RIG-I. IFN-α2b exerted anti-proliferative effect in HSC-3 cells while no such effect was observed in the cells treated with IFN-γ. MDA-5 is known to be associated with tumor cell growth in melanoma. However, overexpression of MDA-5 did not alter the proliferation in HSC-3 cells, indicating that MDA-5 is unrelated to the cell growth in this type of cells. We conclude that MDA-5 is induced by both type I- and type II-IFNs in HSC-3 cells, and this suggests MDA-5 may play a role in immune responses in oral cavity.

Periosteum-derived cells respond to mechanical stretch and activate Wnt and BMP signaling pathways.

The periosteum supplies osteoblasts and nutrients for bone metabolism and is important for osteoblast differentiation and osteogenesis. Recently, periosteum-derived cells have been used for orofacial bone regeneration therapy. However, little is known about the function of the periosteum in physiological bone remodeling. On our hypothesis that the periosteum senses a mechanical stress to induce bone remodeling, we subjected human jaw bone periosteum cells (HJBPCs) to uniaxial stretching for 24 h and characterized their gene expression profiles by microarray analysis. Of62,976 genes detected, 550 genes related to bone metabolism were extracted, and 76 of these genes with large changes in gene expression were short-listed. The results indicated that mechanical stretch in HJBPCs regulated the expression levels of genes involved in the Wingless-type MMTV integration (Wnt) site, bone morphogenetic protein (BMP) signaling pathways, and inflammatory cytokines. We propose that periosteum-derived cells sense mechanical stress and then activate and regulate signals for osteoblast differentiation and osteogenesis.

[Metastatic renal tumor from oral floor cancer: a case report].

A 61-year-old man with oral floor cancer (adenoid cystic carcinoma, T2N0M1) was treated with systemicc hemotherapy and radiation therapy at the department of dentistry and oral surgery in our hospital. He had three lung metastases and renal tumors detected by screening computed tomography. The oral floor cancer responded to the treatment to achieve partial response. However, lung and renal metastases did not respond to chemotherapy. Then, the patient was referred to our clinic to rule out the possibility of lung metastasis from renal cell carcinoma. Laparoscopic left nephrectomy was performed and pathological examination on the renal lesions revealed adenoid cystic carcinoma, which had identical histopathological features to the oral floor cancer. To our knowledge, this is the first report of metastatic renal tumor from oral floor cancer (adenoid cystic carcinoma).

Superselective intra-arterial chemoradiotherapy with docetaxel-nedaplatin for advanced oral cancer.

Cisplatin-based, superselective, intra-arterial chemotherapy concurrent with radiotherapy (SSIACRT) has gained wide acceptance as a common/curative treatment for advanced head and neck cancer. We combined nedaplatin (CDGP) with docetaxel (DOC) as a new combination in SSIACRT for advanced oral squamous cell carcinoma in 2003. Twenty-two patients with advanced oral cancer were treated by radiotherapy (66 Gy) concurrent with superselective intra-arterial DOC (40 mg/body) and CDGP (80 mg/m²) infusion between 2003 and 2009. Complete response was achieved in 18 (81.8%) of the 22 patients. Of the 17 patients with positive neck disease, 16 (94%) were assessed as disease-free. The 5-year overall survival rate was 78.5%, and the major adverse effects were leukocytopenia and mucositis. Five patients (22.7%) developed distant metastases post-treatment. These results indicate that intra-arterial docetaxel-nedaplatin infusion concurrent with radiotherapy is efficacious for advanced oral cancer. The side effects are easily manageable, and the most important outcome of the treatment is the preservation of patients' quality of life (QOL) and improved prognosis.

[A case of submandibular gland cancer in elderly patients showed significant effect by S-1 and intravenous docetaxel chemotherapy concurrent with radiotherapy].

An elderly case of with advanced head and neck cancer treated by intravenous infusion chemotherapy with weekly docetaxel( DOC)and concurrent radiotherapy was reported. The patient was a 77-year-old man. Clinical diagnosis was submandibular gland carcinoma. He was treated by intravenous infusion chemotherapy with weekly DOC and concurrent radiotherapy (total dose 66 Gy). Two months after irradiation, PET-CT showed a partial response (PR). Therefore, chemotherapy of S-1 (80 mg/day) for 2 weeks every 3 weeks was performed. Two months after the end of chemotherapy, PET-CT showed a complete response(CR). This therapy is effective for the treatment of advanced head and neck cancers for elderly inoperable patients.

Expression of interferon-stimulated gene 20 in vascular endothelial cells.

ISG20 is an ribonuclease specific for single-stranded RNA and considered to play a role in innate immunity against virus infections. We herein show that both poly IC, an authentic double-stranded RNA, and IFN-gamma induced ISG20 expression in cultured HUVEC. Poly IC-induced ISG20 expression was inhibited by LY294002, an inhibitor of PI3K, or by RNA interference against IFN regulatory factor three. ISG20 expression was not induced by IFN-beta, loxoribine or CpG oligonucleotide. These results suggest that ISG20 induction by poly IC may not be dependent on the IRF-3-mediated type I IFN induction pathway in HUVEC. ISG20 may be involved in innate immunity against viral infection in vascular endothelial cells.

Expression of retinoic acid-inducible gene-I (RIG-I) in macrophages: possible involvement of RIG-I in atherosclerosis.

AIM: Retinoic acid-inducible gene-I (RIG-I) is one of the genes induced by interferon (IFN)-gamma which plays an important role in atherosclerosis. The aim of this study is to examine if RIG-I is involved in atherosclerosis. METHODS: The expression of RIG-I in atherosclerotic lesions in human aorta was examined by immunohistochemical analysis. The expression of RIG-I in THP-1 monocytic cell line or human monocyte-derived macrophages was studied by western blot and RT-PCR analyses. RESULTS: Intense immunoreactivity for RIG-I was detected in intimal macrophages in atherosclerotic lesions. IFN-gamma slightly enhanced the RIG-I expression in THP-1 cells. Treatment of the cells with phorbol 12-myristate 13-acetate, which induces the differentiation of the cells into macrophage-like cells, significantly enhanced the IFN-gamma -induced RIG-I expression. IFN-gamma also stimulated the expression of RIG-I in monocyte-derived macrophages. CONCLUSION: These results suggest that RIG-I may be involved in differentiation and activation of macrophages, playing a role in atherosclerosis.

Retinoic acid-inducible gene-I mediates RANTES/CCL5 expression in U373MG human astrocytoma cells stimulated with double-stranded RNA.

Retinoic acid-inducible gene-I (RIG-I) mediates part of the cell signaling in response to viral infection. Polyinosinic-polycytidilic acid (poly IC) is a synthetic double-stranded RNA (dsRNA) and mimics viral infection when applied to cell cultures. The CC chemokine, RANTES (regulated on activation, normal T-cell expressed and secreted), is a potent attractant for inflammatory cells such as memory T-lymphocytes, monocytes and eosinophils. In the present study, we demonstrated that poly IC enhances the expression of RIG-I in U373MG human astrocytoma cells. The RNA interference of RIG-I resulted in the suppression of the poly IC-induced RANTES expression. Pretreatment of the cells with SB203580, an inhibitor of p38 mitogen-activated protein kinase, and dexamethasone inhibited the poly IC-induced expression of RIG-I. Furthermore, poly IC upregulated RIG-I in normal human astrocytes in culture and the in vivo injection of poly IC into the striatum of the mouse brain induced the expression of RIG-I in astrocytes. We conclude that RIG-I may be involved in immune reactions against viral infection, at least in part, through the regulation of RANTES expression in astrocytes.

Interleukin-1 induces the expression of vascular endothelial growth factor in human pericardial mesothelial cells.

Vascular endothelial growth factor (VEGF) is a mitogen for endothelial cells. We have studied the production of VEGF by human pericardial mesothelial cells. Mesothelial cells were separated by scraping the pericardial surface during cardiac surgery and cultured. When stimulated with interleukin (IL)-1alpha, pericardial mesothelial cells expressed VEGF mRNA and protein in concentration- and time-dependent manners. Hypoxia was also found to enhance mesothelial VEGF mRNA expression. The cells expressed mRNA for Flt-1 (VEGF receptor 1) and Flk-1 (VEGF receptor 2), and exogenous VEGF was found to have migration-promoting activity on cultured cells. We conclude that pericardial mesothelial cells express VEGF, which may serve as an autocrine growth-regulatory mechanism.

Expression of vascular endothelial growth factor by photodynamic therapy with mono-L-aspartyl chlorin e6 (NPe6) in oral squamous cell carcinoma.

Photodynamic therapy (PDT) is a method for treating pre-cancerous and cancerous lesions of the skin, bladder and oral cavity. However, tumour recurrence after PDT remains problematic despite good initial response. Some studies have shown that PDT induces vascular endothelial growth factor (VEGF) expression in human oral squamous cell carcinoma and other organs. However, little is known about VEGF expression applied to PDT in human carcinoma cell lines. No studies have been conducted of PDT using Npe6 (Npe6-mediated PDT), a second-generation photosensitizer, in the human oral carcinoma cell line, HSC-3 cells. We investigated the expression of VEGF, c-jun and c-fos proto-oncogenes in HSC-3 cells in response to Npe6-mediated PDT. We also addressed the possibility that oxidative damage induced by PDT could lead to an angiogenic response, via VEGF expression. Reverse transcription polymerase chain reaction (RT-PCR) analysis revealed that Npe6-mediated PDT induced the expression of mRNAs for VEGF, c-jun and c-fos in time- and concentration-dependent manners. Desferrioxamine (DFX), an iron chelator, induced VEGF expression, but the expression pattern was different to that of Npe6-mediated PDT. The expression mRNAs for VEGF, c-jun and c-fos induced by Npe6-mediated PDT were inhibited by SB203580, p38 MAPK inhibitors, and the expression of VEGF mRNA was inhibited by cycloheximide (CHX), a protein synthesis inhibitor. The c-jun mRNA expression was inhibited, whereas the c-fos mRNA expression was enhanced by N-acetyl-L-cysteine (NAC), a free radical scavenger. We conclude that Npe6-mediated PDT induces the expression of VEGF, c-jun and c-fos in human oral carcinoma cell line, HSC-3 cell, and at least partly, through the activation of p38 MAPK.

Interleukin-1beta enhances the angiotensin-induced expression of plasminogen activator inhibitor-1 through angiotensin receptor upregulation in human astrocytes.

Plasminogen activator inhibitor-1 (PAI-1) regulates not only fibrinolysis but extracellular matrix remodeling, and angiotensin II is known to play an important role in controlling the expression of PAI-1 in astrocytes. We have studied the effect of interleukin-1beta (IL-1beta), one of major cytokines also active in the nervous system, on the angiotensin II-induced expression of PAI-1 in human astrocytes. Cultures of normal human astrocytes were stimulated with IL-1beta and angiotensin II, and the expression of mRNAs for angiotensin II type 1 receptor (AT1) and PAI-1 was analyzed by reverse transcription-polymerase chain reaction (RT-PCR) or real-time quantitative PCR. PAI-1 protein in astrocyte-conditioned medium was measured by enzyme-linked immunosorbent assay (ELISA). IL-1beta enhanced the expression of AT1 in astrocytes in time- and concentration-dependent manners. After 24-h stimulation, 10 ng/ml IL-1beta and 10 nM angiotensin II increased the levels of PAI-1 protein in astrocyte-conditioned medium by 1.9-fold and 1.8-fold of the basal value, respectively. There was no synergistic effect when the cells were stimulated simultaneously with IL-1beta and angiotensin II. When the cells were stimulated, with angiotensin II, 16 h after the stimulation with IL-1beta, the production of PAI-1 was enhanced by 1.4-fold as compared to the cells stimulated only with IL-1beta. CV-11794, an AT1 antagonist, inhibited the enhanced PAI-1 production in response to angiotensin II. We conclude that IL-1beta increases angiotensin II-induced PAI-1 secretion by astrocytes through the induction of AT1, and the enhanced secretion of PAI-1 may modulate functions of plasminogen activators in the nervous system.

Photodynamic therapy with mono-L-aspartyl chlorin e6 can cause necrosis of squamous cell carcinoma of tongue: experimental study on an animal model of nude mouse.

Mono-L-aspartyl chlorin e6 (NPe6) is an effective photosensitizer with a major absorption band at 664 nm. NPe6 is potentially exploitable for photodynamic therapy (PDT) and does not cause the side effect of prolonged normal skin photosensitization. However, there are no clinical and experimental reports of its use in oral cancer till now. In the present study, we examined the effectiveness of NPe6-induced PDT with a diode laser for treatment of tongue cancer in the nude mouse. Six nude mice with experimental tongue cancer (HSC-3) were given 10 mg/kg NPe6 intravenously. Two hours later PDT was performed using a laser diode at a light dose of 100 J/cm2 and wavelength of 664 nm. Histological changes in the tumors were examined 42-72 h after PDT. Almost all of the tumors developed necrosis, while viable-like neoplastic cells remained mainly in the peripheral region of the tumor in some cases. The mean depth of necrosis below the surface was 2.1 mm. The mean tumor thickness below the surface was 2.3 mm. Tumor thickness coincided with the depth of necrosis. NPe6-induced PDT exhibited tumor selectivity and can effectively cause necrosis of tongue cancers. This therapy could be suggested for treatment of other superficial oral cancer.

Regulation of synthesis of osteoprotegerin and soluble receptor activator of nuclear factor-kappaB ligand in normal human osteoblasts via the p38 mitogen-activated protein kinase pathway by the application of cyclic tensile strain.

Mechanical stress is thought to play an important role in bone remodeling. However, the correlation between mechanical stress and bone remodeling is poorly understood. In this context, using a model of cyclic tensile strain (CTS) toward human osteoblasts, synthesis of osteoprotegerin (OPG) and soluble receptor activator of nuclear factor-kappaB ligand (sRANKL), and the activation of mitogen-activated protein kinases (MAPKs) were examined. The application of 7%, 0.25-Hz CTS once a day for 4 h for 3 successive days simultaneously caused an increase of OPG synthesis and a decrease of sRANKL release and RANKL mRNA expression in osteoblasts. As for MAPKs activation in osteoblasts with the application of CTS, p38 MAPK was activated 10-20 min after the application of CTS, but extracellular signal-regulated kinase (ERK1/2) and c-Jun NH2-terminal kinase (JNK) were not activated by such application. Furthermore, when CTS was applied once a day for 4 h for 1, 2, or 3 successive days to osteoblasts, p38 MAPK activation was maintained during the 3-day period but ERK1/2 activation was downregulated from day to day, simultaneously. Then, when CTS was applied once a day for 4 h for 3 successive days to osteoblasts pretreated with the p38 MAPK inhibitor SB203580 for 1 h, OPG synthesis was dose-dependently suppressed and inhibition of sRANKL release and RANKL mRNA expression was abrogated. These results indicate that biological responses of OPG and sRANKL synthesis in osteoblasts to the application of CTS are regulated via the p38 MAPK pathway and suggest that CTS might modulate and regulate bone metabolism.

Platelet-activating factor enhances the expression of nerve growth factor in normal human astrocytes under hypoxia.

Nerve growth factor (NGF) is required for the survival of neurons. We have addressed the effect of platelet-activating factor (PAF), one of the mediators of ischemic injury of the brain, on NGF expression in astrocytes. Normal human astrocytes in culture were stimulated with PAF, and levels of NGF mRNA and protein were analyzed by reverse transcription-polymerase chain reaction (RT-PCR), real-time quantitative PCR and enzyme-linked immunosorbent assay (ELISA). PAF increased the expressions of NGF mRNA and protein in astrocytes in time- and concentration-dependent manners. After 48-h stimulation, 10 nmol/L PAF increased the levels of NGF protein in astrocyte-conditioned medium by 1.4-fold. The PAF-induced stimulation of NGF expression was further enhanced (2.1-fold of the control) in the cells under hypoxic culture condition. BN52021 (Ginkgolide B), an antagonist for PAF binding sites, suppressed the effect of PAF. We conclude that PAF enhances NGF gene expression in human astrocytes, and the PAF-induced increase in the expression of NGF under hypoxia may benefit the protection of the nervous tissue by promoting neuronal survival.

Platelet-activating factor enhances the expression of vascular endothelial growth factor in normal human astrocytes.

Vascular endothelial growth factor (VEGF) is a potent and specific mitogen for vascular endothelial cells. To examine whether platelet-activating factor (PAF) induces the expression of VEGF in human astrocytes, we stimulated cultured normal astrocytes with PAF and performed semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) or real-time quantitative PCR for VEGF mRNA and enzyme-linked immunosorbent assay for VEGF protein. PAF increased the expression of VEGF in astrocytes in time- and dose-dependent manners. After 24-h stimulation, 10 nM PAF increased the levels of VEGF protein in astrocyte-conditioned medium by 1.3-fold. When the cells were subjected to hypoxia, the PAF-induced production of VEGF was enhanced by 6.7-fold as compared to the unstimulated cells incubated under normoxia. Dexamethasone was found to inhibit the enhanced VEGF production in response to the stimulation with PAF under hypoxia. We conclude that PAF induces VEGF gene expression in human astrocytes, and the PAF-induced increase in the expression of VEGF may modulate nervous tissue injury due to hypoxia.

Production of growth related oncogene protein-alpha in human umbilical vein endothelial cells stimulated with soluble interleukin-6 receptor-alpha: role of signal transducers, janus kinase 2 and mitogen-activated kinase kinase.

Growth-related oncogene protein-alpha (GRO-alpha) is a member of the C-X-C chemokine family with a wide variety of biological activities. We studied the production of GRO-alpha by human umbilical vein endothelial cells (HUVEC) in response to the stimulation with soluble form of interleukin-6 receptor alpha (sIL-6R). sIL-6R stimulated HUVEC to express GRO-alpha mRNA and secrete GRO-alpha protein in concentration-and time-dependent manners. The sIL-6R-induced GRO-alpha expression was inhibited by the pretreatment of the cells with AG490, a janus kinase 2 (JAK2) inhibitor, or with U0126, a MAP kinase-ERK kinase (MEK) inhibitor. sIL-6R also induced the phosphorylation of both Src homology 2-protein tyrosine phosphatase-2 (SHP-2), signal transducer and activator of transcription 3 (STAT3) and MEK. AG490 pretreatment inhibited the MEK phosphorylation but did not affect the STAT3 phosphorylation. We conclude that sIL-6R induces GRO-alpha expression in HUVEC through the activation of JAK2 and MEK.