A Rare Case of Other Iatrogenic Immunodeficiency-Associated Lymphoproliferative Disorders With Multiple Oral Mucosal Lesions During Methotrexate Therapy.

As of the most recent WHO classification of immunodeficiency diseases, lymphoproliferative disorders that occur during treatment with immunosuppressive drugs are classified as "other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPDs)" other than post-transplant lymphoproliferative disorders. Most patients with OIIA-LPD have rheumatoid arthritis as the underlying disease. Research indicates that approximately half of people diagnosed with OIIA-LPD see a remission of their lesion after stopping treatment with methotrexate (MTX), a drug used in rheumatoid arthritis treatment. Hereby, we present the case of an 81-year-old woman with rheumatoid arthritis who developed OIIA-LPD at the bilateral lingual margins. The patient had been receiving MTX for the preceding 10 years. After determining that OIIA-LPD was MTX-related, the patient underwent MTX withdrawal and was treated conservatively. The lesion resolved one month after MTX withdrawal. This case report confirms immunosuppressive drug withdrawal as a potentially effective treatment for multiple OIIA-LPDs of the oral mucosa.

Epstein-Barr Virus-Positive Mucosal Skin Ulcer Resulting in Oral Lesions During Concomitant Use of Tacrolimus and Prednisolone.

Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a subtype of Epstein-Barr virus-positive lymphoproliferative disease with a favorable prognosis that can develop either due to medical interventions or as a consequence of aging. Medical-onset cases caused by immunosuppressive drugs may require a reduction or discontinuation of the causative drugs. However, specific methods for drug adjustment in cases where multiple immunosuppressive drugs are used have not yet been established. Herein, we present the case of a 63-year-old man with interstitial pneumonia who developed an EBVMCU on the right side of his tongue. He was on multidrug therapy with tacrolimus and prednisolone and was treated conservatively by discontinuation of the tacrolimus and switching to prednisolone monotherapy. The lesion resolved within two months following the adjustment. This case report provides evidence that conversion to monotherapy, rather than multiple immunosuppressive drugs, is a potentially effective treatment option for EBVMCU.

Salivary gland function evaluated by diffusion-weighted MR imaging with gustatory stimulation: preliminary results.

PURPOSE: To evaluate the usefulness of diffusion-weighted MR imaging using a transient gustatory stimulation method in patients with xerostomia. MATERIALS AND METHODS: Ten consecutive patients complaining of xerostomia and 10 healthy volunteers were examined with a 1.5 Tesla (T) MR unit. All study subjects completed a questionnaire, and patients underwent salivary gland scintigraphy and Saxon test. T1-, T2-, and diffusion-weighted MR images were obtained before stimulation. One minute after gustatory stimulation with lemon juice, diffusion-weighted sequence was repeated 9 times. A radiologist evaluated signal intensities and apparent diffusion coefficients (ADCs) in parotid and submandibular glands. ADC increase rate (IR) and times to maximum ADC (Tmax) were assessed. RESULTS: IRs showed a moderate positive correlation with washout rates by scintigraphy for parotid (r = 0.554, P < 0.05) and submandibular (r = 0.617, P < 0.01) glands. Furthermore, Tmax values of parotid and submandibular glands were significantly higher in patients (420 ± 226 and 357 ± 232 s, respectively) than in volunteers (181 ± 68 and 200 ± 75 s, respectively) (P < 0.01). CONCLUSION: Our preliminary results indicate that diffusion-weighted MR imaging using a transient gustatory stimulation method is potentially useful for evaluating patients with xerostomia.

Oral complaints and stimulated salivary flow rate in 1188 adults.

BACKGROUND: Recently, oral sensory complaints (OSC) were proposed as a disease entity to represent idiopathic sensory disturbances of dry mouth, burning mouth, and taste disturbance, even though neither the status of OSC in the general population nor its underlying mechanism has yet been elucidated. Moreover, these three OSC-related complaints have not been assessed in combination by means of a visual analog scale (VAS) in a large-scale, community-dwelling population of a broad age range. METHODS: In a 1188-member community-dwelling adult population, comprised of 373 males and 815 females, aged 20-90 years, the three OSC-related complaints and stimulated salivary flow rate (SSFR) were assessed by means of a VAS and modified Saxon test, respectively. Association of each complaint with age, gender, SSFR, and other complaints was analyzed. RESULTS: Increases in both prevalence and intensity of subjective dry mouth and burning mouth were associated closely with decreasing SSFR. Even for taste disturbance, which may be affected less significantly by salivation status than the other two complaints, a significant association was suggested between decreasing SSFR and especially severe taste disturbance. However, these oral complaints were found in considerable prevalence even in the individuals with high SSFR. Often overlapping presentation of these complaints and a close association in intensity between the complaints to each other were also found. CONCLUSIONS: Hyposalivation may be a significant and common etiology for the three oral complaints, although the considerable prevalence of complaints without hyposalivation suggests other etiologies, including those related to the OSC.

The effect of neoadjuvant therapy on the 5-fluorouracil metabolic and relative enzymes of oral squamous cell carcinoma.

To assess the effect of neoadjuvant therapy using tegafur/uracil (UFT) and radiation therapy on the 5-fluorouracil (5-FU) metabolic and relative enzymes, thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), orotate phosphoribosyl transferase (OPRT) and thymidine phosphorylase (TP) in oral squamous cell carcinoma (OSCC), we examined the mRNA expression and immunohistochemical staining status of these enzymes using 17 surgical specimens. Seven patients did not receive any neoadjuvant therapy and 10 were treated with UFT and local irradiation therapy. Our result showed that the mRNA expression of these enzymes in neoadjuvant group was not significantly different from that of non-treated group using real-time quantitative PCR. To confirm the protein expression, we also carried out immunohistological staining of TS and DPD two key enzymes in the 5-FU metabolism, using the same specimens. Immunohistological staining status did not correspond to the results of mRNA analysis completely, though no significant difference between the groups was observed. Furthermore, no significant relationship between the UFT administration period and mRNA expression of the 5-FU metabolic enzymes was observed in neoadjuvant therapy group and also the distribution of the enzyme mRNA expression levels was similar to that of non-treated group. The results suggested that the neoadjuvant therapy of OSCC might not affect the expression status of 5-FU metabolic and relative enzymes in surgical tumor samples and the tumor tissues might serve as a useful specimen source to analyze the expression status of the 5-FU metabolic and relative enzymes and to determine the prospective efficiency of 5-FU-based adjuvant chemotherapy.

Hypermethylation of the RECK gene predicts poor prognosis in oral squamous cell carcinomas.

The RECK gene is a novel tumor suppressor gene that regulates matrix metalloproteinases (MMPs) to inhibit tumor angiogenesis, invasion and metastasis. We investigated the methylation status of the RECK gene in 40 primary oral squamous cell carcinomas (OSCC) and 20 paired adjacent normal mucosa by methylation-specific PCR. Furthermore, we determined the prognostic importance of RECK hypermethylation in OSCC patients. Our findings showed that the RECK gene was methylated in 52.5% (21 of 40) of the primary OSCC. Among the 20 cases with corresponding normal tissues, RECK hypermethylation was detected in both primary tumor (55%, 11 of 20) and adjacent normal mucosa (30%, 6 of 20). Methylation of the RECK gene was not detected in all normal oral mucosa samples of the 12 healthy controls. In univariate analysis, RECK hypermethylation was inversely correlated with recurrence-free survival (p=0.027) and overall survival (p=0.023) of the OSCC patients. Multivariate analysis showed that the methylation status of the RECK gene was the only independent prognostic factor affecting overall survival (p=0.037). The result indicates that hypermethylation of RECK promoter is a common event in human OSCC, occurs concurrently in tumor-adjacent normal mucosa and is correlated with poor prognosis in OSCC patients. Although additional work is needed, hypermethylation of the RECK gene is a promising biomarker in early detection and prognosis for oral cancer patients.

Chemopreventive effect of fermented brown rice and rice bran on 4-nitroquinoline 1-oxide-induced oral carcinogenesis in rats.

The preventive effects of the dietary administration of brown rice and rice bran fermented with Aspergillus oryzae (FBRA) on oral carcinogenesis induced by 4-nitroquinoline 1-oxide (4-NQO) were investigated in male F344 rats. At 7 weeks of age, the animals were given 20 ppm 4-NQO in their drinking water for 8 weeks to induce tongue neoplasms. Groups of rats were fed diets containing 5 or 10% FBRA during the initiation or postinitiation phases of the 4-NQO-induced oral carcinogenesis. The other groups consisted of rats fed 10% FBRA or untreated rats. At the termination of the study (week 32), the incidences, multiplicities of tongue lesions (pre-neoplasms and neoplasms) and the cell proliferation activity estimated by the 5-bromodeoxyuridine (BrdU)-labeling index were compared among the groups. Feeding of 5% FBRA during the initiation phase significantly decreased the incidence (68.2 vs 36.8%; p<0.05) and multiplicity (1.05+/-0.84 vs 0.37+/-0.50; p<0.005) of the tongue carcinoma. When feeding of 10% FBRA occurred after the 4-NQO exposure, the multiplicity of tongue carcinoma was also reduced (1.05+/-0.84 vs 0.52+/-0.60; p<0.05). In addition, the dietary administration of FBRA at both doses significantly decreased the BrdU-labeling index in the oral squamous epithelium (p<0.05). Although a dose-dependent response was not observed, FBRA is effective in suppressing the development of 4-NQO-induced oral carcinogenesis by its concurrent exposure to the carcinogen. The inhibitory effect could be related to the suppression of the hyperproliferation of cells in the tongue epithelium and the radical scavenging activity of FBRA.

A prostaglandin E2 receptor subtype EP1-selective antagonist, ONO-8711, suppresses 4-nitroquinoline 1-oxide-induced rat tongue carcinogenesis.

We previously reported that certain cyclooxygenase (COX) inhibitors could inhibit chemically induced tongue carcinogenesis. In the present study, we investigated the effects of prostaglandin E(2) (PGE(2)) receptor EP(1)-selective antagonist ONO-8711 on 4-nitroquinoline 1-oxide (4-NQO)-induced oral carcinogenesis to know whether an EP(1) receptor involves in oral carcinogenesis. Male Fischer 344 rats were given drinking water containing 4-NQO for 8 weeks (20 p.p.m. for the initial 2 weeks, 25 p.p.m. for 2 weeks, and then 30 p.p.m. for 4 weeks). After 4-NQO treatment, animals were given 400 or 800 p.p.m. ONO-8711 containing diets for 23 weeks. The incidence of tongue squamous cell carcinomas (SCC) in the 4-NQO-treated rats was 64%, while that in the rats given ONO-8711 after 4-NQO exposure was 29 (P<0.05) and 29% (P<0.05) in the 400 and 800 p.p.m. of ONO-8711, respectively. The multiplicity of tongue cancer was also smaller in the 4-NQO + ONO-8711 (400 p.p.m. ONO-8711, 0.35 +/- 0.61; and 800 p.p.m. ONO-8711, 0.29 +/- 0.47; P<0.05), when compared with the 4-NQO alone group (0.88 +/- 0.88). Feeding with ONO-8711 significantly reduced PGE(2) level and cell proliferation activity in the non-tumorous epithelium of the tongue. Also, treatment with ONO-8711 resulted in the decrease in EP(1) immunohistochemical expression in the tongue lesions induced by 4-NQO. The results suggest that EP(1) receptor involves in oral carcinogenesis, and that an EP1-selective antagonist ONO-8711 exerts the cancer chemopreventive effects through the suppression of EP(1) expression, PGE(2) biosynthesis and cell proliferation.

Aberrant promoter hypermethylation of p16 and MGMT genes in oral squamous cell carcinomas and the surrounding normal mucosa.

PURPOSE: Several genetic alterations have been reported to contribute to the development of oral squamous cell carcinoma (OSCC). Recent studies have shown roles of promoter hypermethylation of tumor suppressor genes, including p16 and MGMT, in several types of cancers. The purpose of this study is to examine the hypermethylation status of p16 and MGMT genes in both oral cancers and normal mucosa, surrounding the cancers. METHODS: Promoter hypermethylation status of p16 and MGMT genes were examined by the methylation-specific PCR (MSP) in OSCC (n = 51), verrucous carcinoma (n = 2), and carcinoma in situ (n = 2) tissues. Moreover, normal mucosa surrounding the cancers were also examined in 22 cases out of the 51 OSCCs. As a normal control, oral mucosa from healthy volunteers (n = 18) was used. RESULTS: Aberrant promoter hypermethylation of p16 and MGMT genes was detected in 50.9% (28 of 55) and 56.4% (31 of 55) of the total malignant cases, respectively. As for the 22 OSCC cases, in which paired cancerous tissues and the surrounding normal mucosa were examined simultaneously, promoter hypermethylation of p16 and MGMT genes was confirmed in 72.73% (16 of 22) and 68.18% (15 of 22), respectively. In contrast, as for the surrounding normal mucosa, promoter hypermethylation of p16 and MGMT genes was recognized in 27.27% (6 of 22) cases and 40.91% (9 of 22), respectively. CONCLUSIONS: Hypermethylation of both p16 and MGMT genes was frequently detected in not only OSCC tissues, but also the surrounding normal mucosa around the cancerous tissues. Thus promoter hypermethylation of p16 and MGMT genes are an important, probably early event in oral carcinogenesis.

Preoperative radiotherapy contributes to induction of proliferative activity of CD8+ tumor-infiltrating T-cells in oral squamous cell carcinoma.

In order to evaluate host immune response to cancer, many methods have been applied. However, in the field of oral squamous cell carcinoma, evaluation of host immune response on the basis of proliferative activity of tumor-infiltrating T-cells (TIL) has not been reported. Therefore, we applied double immunohistochemical staining of proliferation markers Ki-67 and CD8 to surgically resected and paraffin-embedded tissue sections for 35 cases of oral squamous cell carcinoma. With this method, there was a significant correlation between the percentage of Ki-67+CD8+TIL and the intra-tumor epithelium infiltration rate of CD8+TIL (P=0.0237). In the process of analysis, we found that the proliferative activity of CD8+TIL tended to correlate (P=0.0859) with clinical N factor (lymph node metastasis), which was previously reported to suppress host immune response. We therefore assumed there was another factor inducing host immune response. The proliferative activity of CD8+TIL was well correlated with preoperative radiotherapy (P=0.0200) while there was no significant correlation between the proliferative activity of CD8+TIL and other clinical factors; age, tumor size, clinical stage, pathological N factor (P=0.5410, 0.7769, 0.1041, and 0.1072, respectively). Our present results strongly imply that preoperative radiotherapy is a very important factor in oral squamous cell carcinoma inducing host immune response regardless of the clinical factors present.

Analysis of ameloblastomas by comparative genomic hybridization and fluorescence in situ hybridization.

In order to characterize the chromosomal alterations in ameloblastomas, a combination of comparative genomic hybridization (CGH) and fluorescence in situ hybridization (FISH) techniques was performed on 9 tumors. Chromosomal alterations including a gain at 1q and losses at 1pter, 10q, and 22q could be detected by CGH only in 1 tumor. Interphase FISH analysis, using centromeric probes for chromosomes 1, 10, and 22 as well as region-specific probes for 1p36 and 10q26, revealed the most frequent alterations to exist in the tumor with the abnormal CGH profile. These alterations included marked to slight increases of monosomic cells for chromosome 10 (91.5%), 10q26 (35.8%), 1p36 (24.4%), and chromosome 22 (18.8%), as well as significant elevations of trisomic cells for chromosome 1 (41.2%). Moreover, FISH analysis revealed a frequent loss of chromosome 22 in all tumors examined, except for one lesion, indicating that loss of the entire or a part of this chromosome is a common event in ameloblastomas, possibly being a predisposing factor to ameloblastoma tumorigenesis.

Dietary garcinol inhibits 4-nitroquinoline 1-oxide-induced tongue carcinogenesis in rats.

The effects of dietary feeding with a polyisoprenylated benzophenone, garcinol, isolated from Garcinia indica fruit rind on the development of 4-nitroquinoline 1-oxide (4-NQO)-induced oral carcinogenesis were investigated in male F344 rats. At 7 weeks of age, animals were given 4-NQO at 20 ppm in the drinking water for 8 weeks to induce tongue neoplasms. They also received the diets containing 100 or 500 ppm garcinol either during (for 10 weeks) or after (for 22 weeks) the carcinogen exposure. The other rats were given tap water without 4-NQO throughout the experiment, and fed garcinol (500 ppm)-containing diet or basal diet alone. At the end of the study (week 32), incidences of tongue neoplasms and preneoplastic lesions, cell proliferation activity in the normal-like tongue epithelium estimated by 5-bromodeoxyurideine (BrdU)-labeling index and cyclin D1-positive cell ratio, and immunohistochemical expression of cyclooxygenase-2 (COX-2) in the tongue lesions were determined. Dietary garcinol significantly decreased the incidence and multiplicity of 4-NQO-induced tongue neoplasms and/or preneoplasms as compared to the control diet. Dietary administration of garcinol also significantly reduced the BrdU-labeling index and cyclin D1-positive cell ratio, suggesting reduction in cell proliferation activity in the tongue by garcinol. The COX-2 expression in the tongue lesions was also suppressed by feeding with garcinol. These results indicate that dietary administration of garcinol inhibited 4-NQO-induced tongue carcinogenesis through suppression of increased cell proliferation activity in the target tissues and/or COX-2 expression in the tongue lesions.

Matrix metalloproteinases 2 and 9 in oral squamous cell carcinomas: manifestation and localization of their activity.

PURPOSE: The process of invasion and metastasis is closely related to the prognosis of oral squamous cell carcinoma (OSCC). Matrix metalloproteinases (MMPs) are a group of enzymes characterized by their ability to degrade extracellular matrix proteins and contribute to the tumor invasion and metastasis. Especially MMP-2 and MMP-9 are known to be related to destruction of basement membrane as collagenases. This study focused on protein expression of MMP-2 and MMP-9 and their extracellular matrix degradation activity in OSCCs. METHODS: Freshly frozen samples from 31 OSCC patients were analyzed for the localization and activity of MMP-2 and MMP-9. Serial frozen sections were used by routine hematoxylin and eosin staining, immunohistochemistry for MMP-2 and MMP-9, and film in situ zymography (FIZ) for gelatinolytic activity. We also evaluated the activity of MMP-2 and MMP-9 by zymography using the same samples as frozen sections. The activated form/proform ratio of MMPs in zymography was evaluated using an image scanner. RESULTS: In MMP-2 the proportion in T3 and T4 clinical stage groups was significantly higher than that in T1 and T2. The proportion in lymph node metastasis cases (N+) was also significantly higher than that in non-lymph node metastasis cases (N-). In contrast to MMP-2, the activated form/proform ratio of MMP-9 was very low, suggesting that MMP-9 is not activated in the matrix degradation of OSCC, although both MMP-2 and MMP-9 protein expression are presented in tumor cells. FIZ revealed MMP in both tumor cells and stromal cells of 70% of the N+ cases and of 47.6% of the N- cases. CONCLUSIONS: These results indicate that two types of proform and activated form matrix metalloproteinases, MMP-2 and MMP-9, are present in human OSCC, and that the activated MMP-2 could be a main enzymatic activity of gelatinolysis in OSCC. Interaction of tumor cells and stromal cells seems to play an important role in the invasion and metastasis of human OSCC. Combination analysis of zymography and FIZ is a useful method to detect activity and localization of MMPs in human OSCC.

Lobular capillary hemangioma of the oral mucosa: clinicopathological study of 43 cases with a special reference to immunohistochemical characterization of the vascular elements.

Clinical and histopathological features were investigated in 43 cases of oral lobular capillary hemangiomas (LCH) with a special reference to characteristics of the vascular elements. The lesions affected females more than males by a ratio of 1:1.5. Average age of the patients was 52.7 years. The lesions involved the gingiva (n = 15), the tongue (n = 13), the labial mucosa (n = 10) and other sites. The lesions appeared usually as a pedunculated mass with ulceration; size of the lesions was up to 15 mm. Histologically, a lobular area and an ulcerative area were distinguished. The density of vessels was about 1045/mm2 and 160/mm2 in the lobular and ulcerative areas, respectively. The average diameter of the vascular lumen was 9.1 5.6 mm (range: 2.8-42.0 mm) and 18.8 20.9 mm (range: 5.6-139.7 mm) in the lobular and ulcerative areas, respectively. In the lobular area, most of the vessels had an inner layer of endothelial cells showing positive reaction for von Willebrand factor (vWF) and CD34, as well as an outer layer of mesenchymal cells showing positive reaction for alpha-smooth muscle actin (ASMA). However, in the ulcerative area, there was a variety of types of vessels consisting of various proportions of both endothelial and ASMA-positive perivascular mesenchymal cells. These results indicate that most of the vascular elements in the lobular area resemble more pericapillary microvascular segments than they do capillaries. Thus, the authors propose the term 'lobular pericapillary hemangioma' to represent this type of lesion.

Usefulness of low-level laser for control of painful stomatitis in patients with hand-foot-and-mouth disease.

OBJECTIVE: The aim of this study was to evaluate the usefulness of low-level laser therapy (LLLT) for the control of painful stomatitis in patients with hand-foot-and-mouth disease (HFMD). BACKGROUND DATA: LLLT has been successfully applied to various painful oral mucosal diseases, although there have been few reports on LLLT for HFMD patients. MATERIALS AND METHODS: Through a randomized double-blind placebo controlled trial, the painful period of HFMD stomatitis was compared between the LLLT group (n=11) and the placebo LLLT one (n=9), which had similar clinical backgrounds. The LLLT parameters supplied were as follows: wavelength of 830 nm, power of 30 mW, frequency of 30 Hz, and energy output of 1.1 J/cm2. Acceptability and safety of the treatment were also evaluated. RESULTS: The painful period was shorter in the LLLT group (4.0 +/- 1.3 days) than in the placebo LLLT one (6.7 +/- 1.6 days) with a statistically significant difference (p<0.005). The treatment was judged acceptable for 90.0% (18 of 20) of patients. No adverse events were observed in any cases. CONCLUSION: LLLT is a useful method to control HFMD stomatitis by shortening the painful period, with its high acceptability and lack of adverse events.