Abstracts of papers presented at the forty-eighth annual meeting of the American Academy of Oral Pathology

Abstracts 0.f papers presented at the forty-eighth annual meeting of the American Academy of Oral Pathology NONGINCIVAL FIBROUS HYPERPLASIA ASSOCIATED WITH CYCLOSPORINE. Woo S. Brigham and Wom-

ens’s Hospital, Harvard School of Dental Medicine, Boston,, Mass. Gingival overgrowth is a comm.on side effect of cyclosporine therapy. This occurs in approximately 30% of patients who have received renal allografts as opposed to only 4%~of patients who receive allogenic marrow transplants. Mucosal overgrowths have not been observed in edentulous areas of the mouth in such patients. Objective: This paper reports three cases of nongingival fibrous nodules that arose in three patients who were receiving cyclosporine for the control of graft-vs-host disease after allogenic bone marrow transplantation. Findings: These nodules, one on the tongue dorsum and two on the buccal mucosa, grew rapidly within a period of 1 to 3 months and raised the suspicion of relapse of their original hematologic malignancies. Histologically, the nodules consisted of a proliferation of fibrous tissue and some granulation tissue, with varying degrees of inflammation. Conclusion: Because these masses arose in a background of clhronic graft-vs-host disease, chronic inflammation and repair (such as is present in the gingiva), combined with a susceptibility of fibroblast subpopulations to the effects of cyclosporine, may play a role in inciting such a tissue response. ENDODERMAL SINUS TUMOR (YOLK SAC TUMOR) ARISING IN THE PALATE OF A CHILD Fantasia JE,

Sciubba JJ, Val,derrama E. Departments of Dental Medicine and Pathology, Long Island Jewish Medical Center, New Hyde Park, N.Y. Extragonadal germ cell tumors of the head and neck region account for only 5% of all benign and malignant germ cell tumors. The majority of these tumors are present in the neonatal period and are classified as pure teratomas. Malignant germ cell tumors are rare neoplasms and affect children at older ages (6 to 11 months) and have been described arising in the oropharynx, nasopharynx, and floor of mouth. This report is that of a variant of malignant germ cell tumor, endodermal sinus tumor (yolk sac tumor) arising in the palate of a 15-month-old boy. Laboratory tests demonstrated a serum alpha-fetoprotein level of 1’70 rig/l (N = 8.5) and alpha-l-antitrypsin level of 337 mg/dl (N = 78-200). These tumor markers are useful in establishing the diagnosis, staging, and determining persistence of tumor af-

ter treatment and recurrent disease. Immunohistochemistry was not helpful in establishing the diagnosis. This case illustrates the importance of considering a germ cell tumor in the differential diagnosis of an epithelial-like malignancy arising in the palate of a child. EXTRAOSSEOUS CALCIFYING EPITHELIAL ODONTOGENIC TUMOR, CLEAR-CELL VARIANT: CLINICOPATHOLOGIC FEATURES OF 2 CASES AND REVIEW OF THE CURRENT LITERATURE. Houston G, Fowler C.

Wilford Hall Medical Center, San Antonio, Tex. The calcifying epithelial odontogenic tumor (CEOT) was first described as an entity by Pindborg in 1955. This intraosseous odontogenic neoplasm occurs most frequently in persons over 40 years of age. Most cases arise in the posterior mandible, present as a well-circumscribed unilocular radiolucent area with foci of radiopacity, and are associated with an unerupted or impacted tooth. Microscopically, the CEOT is composed of polyhedral epithelial cells that most investigators believe originate from the stratum intermedium. A well-recognized form of this neoplasm is the clear-cell variant in which the lesional cells exhibit a clear, vacuolated cytoplasm rather than the usual eosinophilic cytoplasm. An extraosseous tumor is also known to occur but is quite rare with only nine reported cases. In the present study two additional cases of extraosseous CEOT are reported, both of which exhibited a prominent clear-cell component. The clinical and histopathologic findings of these two cases are compared with the nine reported cases from the English-language literature. The age range for the 11 cases was from 12 to 64 years with the mean age of 34.4 years at the time of diagnosis. Six of the tumors involved females and five involved male patients. There is a predilection for the mandibular gingiva (seven cases) with the remaining four cases involving the maxillary gingiva. Microscopically, six of the lesions exhibited a predominant clear cell component. Appropriate management of the extraosseous CEOT consists of simple excision. No recurrences have been recorded. AMELOBLASTOMA. Gardner D, Dubielzig R. University of Colorado, Denver, and University of Wisconsin, Madison. HE sections of seven typical examples of canine keratinizing ameloblastoma were studied and com-

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pared with the well-recognized histologic features of human ameloblastoma. Two examples were stained with Congo red and examined by polarizing microscopy. This variant of canine ameloblastoma exhibits the typical basal cell changes of ameloblastoma, but the central cells of the epithelial islands are spindleshaped and closely packed. Stellate reticulum is not usually present. The striking feature is that these tumors exhibit a marked tendency to keratinize with subsequent calcification of the keratin. Such keratinization and calcification occurs infrequently in human ameloblastomas and is never as marked as in the canine examples. Some examples exhibit amyloid, a feature that has been reported occasionally in human ameloblastomas but that is not a characteristic feature. The biologic behavior of these canine tumors appears to be similar to that of human ameloblastomas. CLiNICAL GANISMS

SIGNIFICANCE OF ACTIN IN PERIAPICAL LESIONS Collins B, Baugh-

man R. University of Florida, Gainesville.

Periapical lesions containing colonies of actinomyces-like organisms (ALO) have been reported to be problematic in their clinical treatment. Biopsy submissions of all periapical pathoses containing AL0 from the University of Florida College of Dentistry Oral and Maxillofacial Biopsy Service files were examined. Actinomycosis has been known to occasionally complicate the healing of periapical lesions, requiring extended high-dose antibiotic therapy for resolution. The objective of this study was to evaluate whether or not lesions containing AL0 behaved differently on a clinical basis than those without ALO. A questionnaire for submitting doctors was developed and pilot-tested for clarity. The questionnaire was then mailed to all dentists who had originally submitted apical specimens containing ALO, requesting responses based upon treatment record entries. A randomly selected control group of sequential apical surgical submissions without AL0 was similarly evaluated. AL0 lesions were found most often in whites (70%), females (5 l%), and in the maxilla (63%). Apical surgery appeared to be curative. No significant differences in clinical behavior of the lesions (e.g., pain, swelling, or presence of a sinus tract) were observed between the two groups. DISEASE TO THE JAWS. Summerlin D-J, Tomich CE, Abdelsayed R. Indiana University, Indianapolis. METASTATIC

Discontinuous spread of malignancies to the jaws represents approximately 1% to 3% of all metastases. As a result of this relative infrequency, these lesions are often misdiagnosed as a primary disease process.

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY December 1994

The intent of this study is to analyze the clinicopathologic features of metastatic disease to the jaws. The archives of the Indiana University Oral Pathology service were reviewed and produced 124 cases of metastatic disease to the jaws. Of these cases, 63% occurred in males and 47% were found in the mandible. Soft tissue metastases accounted for 16% of the cases. When symptoms were described, nondescript pain was the most common presenting factor, followed by paresthesia. On radiographic examination, these lesions presented as destructive, illdefined radiolucencies. However, occasional primarily osteoblastic lesions were observed. Breast, lung, and GI primaries represented 50% of the primary sites, whereas 27% were of unknown origin. This large study of 124 cases is consistent with the existing literature, but demonstrates that many more sites than the mandible tend to be involved in this process In addition, metastatic disease to the jaws is often not considered in the clinical work-up and may represent the first manifestation of the malignancy. SCLEROMA (RHINOSCLEROMA). Car10sR, Koutlas I, Sedan0 H. Francisco Marroquin University, Guatemala, and University of lwinnesota, Minneapolis. RESPIRATORY

Respiratory scleroma (rhinoscleroma) is a chronic granulomatous-atrophic infection produced by Klebsiella rhinoscleromatis (KR), a gram-negative aerobic coccobacillus. This disease is endemic in Africa, Central and South America, South Central and East Europe, the Middle East, and China. Sporadic cases have been reported in the United States, generally in persons who have migrated from the aforementioned areas. The majority of cases affect the nose but extension to the soft and hard palate, upper lip, and maxillary sinuses is frequent. Nine cases are reported here from Guatemala, three with oral Iesions. Differential diagnosis should include midline lethal granuloma, rhinosporidosis, squamous cell carcinoma, and leishmaniasis among others. EM stu Mikulicz cells with single nucleus at the cell periphery with diffuse chromatin pattern. Cytoplasmic vacuoles were present containing viable bacilli with a mucopolysaccharide coat. Electron dense “A granules” lined the polysaccharide layer and tended to accumulate at the ends of the bacilli. Less electrondense “B-granules” were found extracellularly. ALLERGIC FUNGAL SINUSITIS: POINTS OF CONSIDERATION. Arendt D, Gudewicz T, Hunsaker D, Dull Ikf.

Naval Medical Center, San Diego, Calif.

As early as 1976 a histologic similarity between a specific type of fungal sinusitis and allergic broncho-

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pulmonary aspergillosis was noted. Numerous fungi have been implicated ranging fralm Aspergillus species, Demateaceous, Mucor and even Candida. A decade ago Katezenstein favored this noninvasive allergic fungal sinusitis to be caused by Aspergillus NOS and used the term AAS (allergic fungal sinusitis). However, current literature with positive cultures favor the Demateaceous fungi. The challenge in diagnosis of this process often resides with correct sampling at time of surgery or grossing. Not just the soft tissue but the mucoid material and or “peanut butter” like material should be the wet tissue source for culture and histologic exam. Morphologically these fungi all may appear “hyphal” and cannot be differentiated without culture. The demateaceous fungi typically reside in the “allergic mucin” whereas the other fungi may be found in the stroma. Ancillary studies that further suggest an allergic etiology for AFS include peripheral eosinophilia, immediate cutaneous reaction to fungal specific antigens, positive RAST and SETS. Therapy is often dictated by extent of the disease. Earlier diagnosis would most certainly reduce the morbidity associated with current treatment modalities. ASSOCI.ATION OF PATTERNS OF INFLAMMATION IN LABIAL SALIVARY GLANDS WITH KERATOCONJUNCTIVITIS SICCA: ANIALYSIS OF 618 PATIENTS SUSPECTED OF HAVING SJ&REN’S SYNDROME. Daniels T,

Whitcher J. lJniversit,y of California, San Francisco. Objective: To determine the association between patterns of inflammation in labial salivary glands (LSG) and the ocular component of Sjiigren’s syndrome ((SS). Methods: We classified LSG biopsy specimens from 618 patients suspected of having SS into focal lymphocytic sialadenitis (FLS) (N = 3 15), other chronic sialadenitis (CS) (N = 261) or other diagnoses. We then measured the association of the other component of primary SS, keratoconjunctivitis sicca (KLCS), with FLS, CS, parotid flow rate, and xerostomia. Results: FLS rather t&an CS was associated with diagnoses of KCS (x2 = 191, P < 0.0001). The severity of KCS correlated directly with the severity of FLS (r =: 0.52, P < O.OOOl), but not CS, and correlated inversely with parotid flow rate in those patients having FLS (r = -0.29), but not in those with CS (r = -0.103). Xerostomia was marginally associated with KCS (x2 = 5, P = 0.02). Conclusion: The stronger asso’ciation of FLS in a LSG biopsy with KCS makes FLS the best criterion presently available for diagnosing the salivary component of SS. CS is a common feature of LSGs but is neither associated with SS nor an end stage of primary SS. Histopathologic examination of salivary tissue is currently

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essential to diagnose primary SS and those cases of secondary SS lacking KCS, especially cases to be used for studies of SS. CLINICOPATHOLCXIC FEATURES OF 57 CASES OF SALIVARY GLAND CYSTADENOCARCINOMAS. Foss

R, Ellis G, Auclair P. Armed Forces Institute of Pathology, Washington, DC The clinicopathologic features of 57 cystadenocarcinomas retrieved from the files of the AFIP were studied. Excluding five VA/Military cases, males and females were equally affected. Patients ranged in age from 20 to 86 years (mean 58.8, median 64). Persons over age 50 accounted for 71% of the cases. Thirty-seven tumors (65%) occurred in major salivary glands, 35 in the parotid and two in the sublingual glands. The 20 minor salivary gland tumors (35%) involved, in descending order, the lips, buccal/ cheek area, palate, tongue, retromolar area, and floor of mouth. Grossly, the lesions were described as cystic or multicystic masses that ranged in size from 0.4 to 6.0 cm. All tumors microscopically demonstrated an invasive, cystic growth pattern and 75% had a conspicuous papillary component. The predominant cell type varied among tumors and included small cuboidal cells (35 cases), large cuboidal cells (9 cases), and tall columnar cells (7 cases). Six cases exhibited an admixture of cell types. Ruptured cysts with hemorrhage and granulation tissue were common. All 39 patients with follow-up data were either alive or had died of other causes and were free of tumor a mean interval of 52 months after their initial surgery. Three tumors recurred locally (mean interval, 76 months). Three tumors were metastatic to regional lymph nodes at the time of diagnosis and one patient developed a regional lymph node metastasis after 55 months. Salivary gland cystadenocarcinomas represent a distinct, albeit heterogeneous, group of malignancies that have an indolent biologic behavior. ROLE OF HISTOCYTOLOGIC GRADING OF MUCOEPIDERMOID CARCINOMA OF MAJOR SALIVARY GLANDS IN PROGNOSIS AND SURVIVAL. Hicks J,

Flaitz C, El-Naggar A, Luna M, Batsakis J. Baylor College of Medicine, Texas Children’s Hospital, University of Texas-Houston Dental Branch, University of Texas MD Anderson Cancer Center-Houston The purpose of this clinicopathologic and how cytometric study was to evaluate a modified Healy grading system (Batsakis and Luna, AORL 1990; 99:835) and compare various clinical, pathologic, and flow cytometric parameters and overall survival

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among mucoepidermoid carcinomas (MEC) of different grades. Forty-eight patients with seven low grade (LG), 23 intermediate grade (IG), and 18 high-grade (I-IG) MECs of parotid (n = 43) and submandibular (n = 5) glands were studied. Data were analyzed using univariate categorical statistics (Wilcoxon, Kruskal-Wallis tests). Mean ages were 42y LG, 47y IG and 59y HG MECs (p= 0.02). Gender ratio (p < 0.001) changed from female predominance in LG (6F:lM) and IG (2.1F:lM) to male predominance in HG (3SM:lF). Mean tumor stage was 1.4 LG, 2.4 IG and 3.6 HG MECs (p < 0.005). Tumor size increased from 2.1 cm for LG MECs to 3.8 cm for IIG MEC (p = 0.01). Margins were involved by tumor in 0% LG, 44% IG and 61% WG MECs (p < 0.001). Lymph node involvement was 0% LG, 22% IG and 72% HG MECs (p < 0.001). DNA anueploidy (DNA Index <0.9 or > 1.1) was present in 0% LG, 13% IG and 28% HG MECs (p = 0.05). Proliferative fraction (S + G&I) was 5% LG, 7% IG and 13% HG (p = 0.008). Radiotherapy was administered in 14% LG, 35% IG and 61% HG MECs (p = 0.03). Recurrences (local and/or metastatic) occurred in 0% LG, 39% IG and 41% HG MECs (p = 0.009). Survival was decreased significantly with increasing tumor grade (p < 0.0001) - died of disease was 0% LG, 30% IG, and 78% HG MECs. Histologic grading of mucoepidermoid carcinomas of major salivary glands, using the modified Healy three-tiered system, correlates well with clinical, pathologic, and flow cytometric factors that influence the prognosis and overall survival in affected individuals. (American Cancer Society Clinical Qncology Grant #20401-92 and NH-Cancer Grant #16672 Biostatistical Resource.) LOW-BRAVE MUCOEPIDERMOID CARCINOMA OF MINOR SALtVARY GLANDS: A ~ET~~~PEC~VE VIOR AND RATE OF ~~C~RR~NCE. Tifee

J, Weathers D. Emory University School of Medicine, Atlanta, Ga.

Low-grade mucoepidermoid carcinomas of minor salivary glands have been reported in virtually every location in which minor salivary glands exist. Fortyseven such lesions were retrieved from the files of the oral pathology service of Emory University from 197 1 to 199 1. Of these 47 cases, follow-up information was available on 12. The ages of these patients ranged from 21 to 78 years with an average age of 52.8 years. Of the 12 cases, two occurred centrally within the mandible. Of the lesions confined to soft tissue, one (10%) recurred 4 years after the initial excision. One

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of the centrally occurring cases recurred 20 months after initial treatment whereas the second showed no evidence of recurrence 24 months after treatment. This study is consistent with previous reports showing that centrally occurring lesions are more aggressive than their soft tissue counterparts. However, the intraoral soft tissue lesions in our study showed only a 10% recurrence rate and no local or distant metastases. This would tend to suggest that including all such lesions under the diagnosis of “carcinoma” may be overstating their potential for aggressive behavior and that the previously used term “mucoepidermoid tumor” may better describe their actual behavior. AMELOBLASTlC FIBROSARCOMA AND ITS RELATIONSHIP TO AMELOBLASTIC FIBROMA. ~~~1~~ S, Parker D, Kapadia S, Budnick S, Barnes L. University of Pitts-

burgh Medical Center, Pa. and Emory Wniversity, Atlanta, Ga.

Ameloblastic fibrosarcoma (AFS), the malignant counterpart of the ameloblastic fibroma (AF), is a rare odontogenic tumor characterized by benign epithelium and a malignant fibrous stroma. Oftentimes, with repeated recurrences the epithelial component of AFS completely disappears, making diagnosis difficult. Review of the literature revealed 44 reported cases, and we add five new cases of AFS. When all cases of AFS are analyzed, the mandible is the most common location compared to the maxilla (3.5: 1) and the male to female ratio is 1.3: 1. ‘The average age of presentation is 28.1 with a range of 3 to 83 years. In contrast, the average age of presentation of AF reported in the literature ranges from 14.6 to 22 years. This age difference suggests a possible step-wise progression of a benign to a malignant tumor. In fact, 46% of the reported AFS, including 4 of 5 of our cases: arose in previously benign AF. Interestingly, these patients had an average age of 32.5 as compared to an age of 21.7 from those patients whose tumor probably arose de novo. Some have suggested more aggressive surgical treatment of AF because of its high recurrence rate (18.3% to 43.5%), as well as the possibilityof malignant transformation. Thedata presented here would most certainly support this recommendation. Rather than enucleation or curettage, an en-bloc resection, similar to the surgical management of ameloblastoma, along with clinical follow-up for at least 5 years in view of the high recurrence rate would be warranted. The surgical management of AFS is dictated by the clinical extent of disease, but will usually necessitate at least a partial mandibulectomy or maxillectomy.

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Volume 78, Number 6 CEMENITOBLASTOMA REVISITED: A CLINICOPATHOLOGIC STUDY OF 44 CASES AND REVIEW OF THE LITERATURE. Fowler C, Brannon R, Carpenter W, Corio

R. Wiljford Hall Medical Center, San Antonio, Tex., Armed Forces Institute of Pathology, Washington, DC, University of Paci$c, San Francisco, Calif., Johns Hopkins University, Baltimore, Md. The ~cementoblastoma (CB) is a.rare benign odontogenic tumor d ectomesenchymal origin arising from neoplastic cementoblasts. It differs from the osteoblastoma primarily by its cell of origin and its fusion to the tooth root. The purpose of this study is to report the clinical and pathologic findings in 44 cases of CB accessioned at the AFIP and compare these with 66 previously reported cases from the Englishlanguage literature with special emphasis given to the clinical behavior, treatment, and recurrence rate of this neoplasm. For all cases combined, the mean age at diagnosis was 21.4 years, and the male-to-female ratio was 1.2/l. Over 70% occurred in the mandible with the first molar being the most commonly affected, tooth. Radiographically, over 90% were well-defined radiopaque or mixed-density lesions. Three lesions were radiolucent. Follow-up was obtained in 34 of 4’4 cases from the current study with a mean follow-up time of 5.5 years. Recurrence was documented in 13 cases (38.2%) in contrast to the literature where only 2 of 28 cases with adequate follow-up recurred (7.1%). Jaw expansion and erosion or perforation of the cortex were common findings in lesions lhat subsequently recurred. Because recurrence and continued growth are possible if lesional tissue remains after initial surgery, appropriate treatment should consist of removal of the lesion along with the affected tooth or teeth followed by thorough curettage. GIANT CELL TUMOR OF THE MAXILLA: REPORT OF A CASE. DeLano R&I, Allen CM. The Ohio State Uni-

versity, Columbus. The giant cell tumor of bone (GCT) typically appears as an expansile radiolucency involving the epiphysis of a long bone during the 3rd and 4th decades of life. Although rare cases of GCT have been reported in the jiaws, controversy exists regarding their relationship to the central giant cell granuloma (CGCG). Some authorities feel that GCT and CGCG are distinct entities with an overlapping histologic spectrum, whereas others believe the two lesions represent a continuum of a single process. Report of that Case: A 21-year-old black female presented with an expansile, markedly destructive radiolucency of the

left maxilla that had caused pain for 3 weeks. Histologic sections showed numerous large, benign-appearing multinucleated giant cells set in a highly cellular background of spindle-shaped cells characterized by pleomorphism, nuclear hyperchromatism, and prominent mitotic activity ( 18 mitoses/ 10 high-power fields). After consultation with several other centers, a diagnosis of giant cell tumor, Grade II, was made, and the patient underwent a partial maxillectomy, followed by five rounds of chemotherapy. At 6 months after surgery, the tumor appears to be controlled. The clinical, radiographic, and histopathologic features of this lesion suggest a distinctly more aggressive biologic behavior than the routine CGCG, and thus it should be considered a different entity. ORAL HAIRY LEUKOPLAKIA IN NONIMMUNOSUPPRESSED PATIENTS: REPORT OF FOUR CASES. Loza-

da-Nur F, Robinson J, Regezi J. University of California at San Francisco. Hairy leukoplakia (HL) was first described as a marker of HIV infection. Today HL has come to represent a marker of’ immunosuppression and not just HIV infection. Last year the first three cases of HL in non-HIV, nonimmunosuppressed patients were reported. Although molecular mechanisms have not been fully elucidated, Epstein-Barr virus (EBV) appears to play a significant role in its etiopathogenesis. We report four additional cases; two of which occurred in non-HIV, nonimmunosuppressed patients after response to the use of high-potency topical steroids for the treatment of oral vesiculoerosive disease. Our cases illustrate that HL is not exclusive to immunosuppressed patients. Before suggesting HIV antibody testing in apparently low-risk, nonrisk patients, in situ confirmation of EBV should be done in addition to taking a thorough medical and social history to determine ‘“risk factors.” CARCINOMA OF THE SUBLINGUAL GLAND: REPORT OF THREE CASES. Weitzner S. University of Cincin-

nati, Cincinnati. The sublingual gland is rarely the site of an epithelial salivary gland neoplasm; the overwhelming majority are carcinoma. Three patients with sublingual carcinoma are presented with a review of the previously reported 65 cases. Two had adenoid cystic carcinoma with perineural involvement: a 72-year-old woman with a metas,tasis in a cervical lymph node and was alive with no ‘evidence of disease (WNED) 7 months after excision, radical neck dissection, and radiation therapy, and an 82-year-old man who died

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after a stroke but WNED 16 months after excision and radiotherapy. The third, a 33-year-old man, had low-grade mucoepidermoid carcinoma and WNED 4 years after excision. Of the 68 casesof sublingual gland carcinoma, including the present three, there were 26 adenoid cystic, 14 mucoepidermoid, 9 each carcinoma ex mixed tumor and adenocarcinoma, one each squamousand undifferentiated carcinoma, and four not specified. Sex and age were each available for 34 patients. Twenty were women and 14 men. Their agesranged from 24 to 82 years; 17 were in the 5th and 6th decadesof life. Prognosis dependsupon the carcinoma type, stageof disease,adequacy of primary excision, and radiotherapy if indicated and appearsto parallel that for similar tumors a%the parotid and submandibular gland. PRODUCTION

AND LOSS OF IL-la WITHOUT SECREE MARROW DERIVED MACROPHAGES.

lbert L. University of Alberta, Edmonton, Alberta. After synthesis in stimulated macrophages, degradation, and loss of IL-la, a pluripotent pro-inflammatory cytokine has been related to a slow secretory process.Whether stimulated macrophagescan downregulate cell-associated IL-la without externalization or are irreversibly primed to deliver an IL-1 signal is not known. In this study, cell-associated IL-la levels in Gultured C3H He.I mousebone marrow derived macrophages (BMMs) and in culture media were measured by bioassay after BMM stimulation over variable times with GM-CSF and TNFor. This cytokine combination stimulates BMMs to produce IL-1 activity about 24 and 13.7 times respectively (normalized to ng DNA), that produced in cultures stimulated only with TNFa or GM-CSF. The cellassociated IL-l activity is almost completely abrogated with IL- 1 CI:but not ,8 antibody. Cell-associated IL-la levels could be stably sustainedwith continued cytokine stimulation for at least 48 hours but cytokine removal resulted in a 24-fold loss of cell-associated IL-l a within 24 hours. No IL-1 activity in culture media was measured during the IL-1 N production or lossperiods. Assays for IL-l receptor antagonist in culture media were negative. Theseresults indicate that cell-restricted regulation of IL-1 cylevels is possibleand that externalization of IL-1 bioactivity is not an inevitable concommittant of production in macrophages. EGFR IN HPV INFECTED ORAL SMOKELESS TOBACCO KERATOSES, DYSPLASIA, AN CANCER. Greer R,

Shrover K, Hoernig G. University of Colorado School of Dentistry, Denver. Epidermal growth factor receptor (EGFR) has been reported to be overexpressedin tumor cell lines,

sometimes in conjunction with gene amplification. Recent studies have also reported the overexpression of EGFR in somebenign papillomavirus-induced lesions.Studies in our laboratory over the past decade havedemonstratcd that human papillomavirus (HPV) can influence proliferation and differentiation of human cells in tissue culture. The current study was developed in an attempt to determine if there is overexpressionof EGFR in HPV infected oral smokelesstobacco keratosis, oral epithelial dysplasia, verrucous carcinoma, and squamouscell carcinoma. Ten grade III smokelesstobacco keratoses, 10 grade I squamous cell carcinomas, 10 severe epithelial dysphasias,10 verrucous carcinomas, and 10 samplesof normal oral cpithelium, all of which were determined by polymerase chain reaction to contain HPV DNA, were examined immunohistochemically for the presenceof EGFR, along with similar numbers of non IIPV infected lesions. EGFR presence was quantified on the basisof staining intensity and distribution. There was a noticeable difference in the staining characteristics among the five gradesof lesions.Tissue samples from HPV-infected smokelesstobacco keratoses,dysplasias,and cancers showedincreased EGFR staining compared with normal epithelium, and non-HPV-infected lesions, suggestingthat there were higher levels of EGFR on the surface of these cells. {Supported by STRC grant #0278.) DETECTlON OF HUMAN ~APlLLOMAV~R~§ IN EPITHELIAL NEOPLASMS OF THE HEAD AND N SITU HYBRIDIZATION AND POL~M~RAS~ EACTION AMPLIFICATION. Murrah VA, Gilchrist EB,

Copete MA. The University of Texas Health Science Center at San Antonio, San Antonio. Human papillomavirus (HPV) hasbeen implicated asan etiologic factor in epithelial malignancies of the head and neck. HPV-16 and HPV-18 genetic sequences have been shown to transform normal oral keratinocytes in vitro with the integration of multiple copies of intact viral genome into the immortalized cells. The purpose of this investigation was to determine the incidence of HPV genomic material in archival formalin-fixed, paraffin-embedded epithelial neoplasmsof the head and neck, using both in situ hybridization and the polymerase chain reaction (PCR). Archival specimenswere obtained from the Oral, Head and Neck Pathology Laboratory at The University of Texas Health Science Center and Medical Center Hospital, San Antonio, Texas. Tissue in situ hybridizations for the presence of HPV types 6-11, 16-18 and 31-33-35 were performed utilizing the Vira-Type in situ kit (Life Technologies, Inc., Gaithersburg, &Id.). PCR was performed on extracted DNA using two sets of consensusprimers to amplify an 850 base pair (bp) sequenceof the E-l

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Volume 78, Number 6 open reading frame (ORF) and a 450 bp sequence of the L-l ORF. An additional primer set specific for a 280 bp slequence of the human P-globin gene served as an intlernal control. Four of 94 (4.25%) specimens were positive for one or more HPV -typesby the in situ technique. PCR ldetccted HPV in 3 of 64 (4.7%) specimens where human P-globin was successfully amplified. Casesincluded 56 squamouscell carcinomas (SCC), three carcinomas in situ, one severedysplasia, one verrucous hyperplasia, one mild epithelial dysplasia, one focal epithelial hyperplasia, and one squamous papilloma. In conclusion, although there may be a role for this virus in a minority of head and neck lesions, the paucity of SCCs with detectable HPV in this study suggeststhat, in the majority of cases,SCCs of the head and neck are unlikely to be related to human papillomavirus infection. IMMUNOREACTI\/E TRANSFORMING GROWTH FACTOR ALPHA IN PROLIFERATIVE VERRUCOUS LEUKOPLAKIA. Kannan R, Mallery S, Stoner G. Ohio State

University, Columbus. Transforming growth factor-alpha (TGF-ALPHA) is a potent mitogen of the Epidermal Growth Factor family, with 33% sequencehomology to epidermal growth factor. Altered TGF-ALPHA immunoreactivity has been reported in oral squamouscell carcinoma, where it confers a growth advantage on the transformed cells. Becausethe exact stage of action of TG F-ALPHA in carcinogenesisis not well defined, demonstrat,ion of altered expressionin premalignant lesionssuch as proliferative verrucous leukoplakia (PVL) would be very significant. The purpose of this study was to determine for the first time TGFALPHA expressionin PVL and compare it with normal mucosaand oral squamouscell carcinoma (SCC). Formalin-fixed paraffin-embedded sectionswere used for immunohistochemical staining of TGF-ALPHA using mouse monoclonal antibody and avidin-biotinperoxidase proce,dure. Ten PVL specimens, five of normal mucosa and SCC were evaluated. Normal mucosal epithelium showed negative or low positive staining for TGFALPHA that was limited to the spinous cell layer. In contrast, PVL lesionsexhibited strong positive staining in the spinous and granular cell layers whereas the epithelium in SCC exhibited moderate to strong positive staining in the welldifferentiated areas. Our results indicate that increased immunoreactivity occurs early in the process of malignant transformation and could be a significant indicator of premalignancy. These findings suggest that TGF-ALPHA expressionis associatedwith a cellular growth advantage early in the process of malignant transformation. Studies are ongoing in our lab using cell lines from PVL, SCC, and normal mucosafor mRNA analysis and receptor expressionthat

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would further our understanding of PVL and provide a marker for diagnosisand efficacy of preventive and treatment procedures. CULTURED AIDS-KS ICELLS DEMONSTRATE ABERRANT CYTOPROTECTION. Mallery S, Ng Bautista C,

Stephens R. Ohio State University, Columbus. The advent of the AIDS epidemic has markedly increased the incidence and severity of Kaposi’s sarcoma (KS) and subsequently stimulated interest in KS pathobiology. Notably, many patients that develop AIDS-KS relate a history of a Koebner-type phenomenonin which local trauma is followed by the subsequentdevelopment of a KS lesion at the injured site. This local trauma would elicit an inflammatory cell response,and despite the HIV-mediated loss of CD4+ lymphocytes, there is generally a sparing effect on AIDS patients’ macrophages and neutrophils. A component of phagocytic activation is the initiation of a cellular oxidative burst, that results in the generation of potentially mutagenic reactive oxygen species (ROS) such as H202. The objective of this study was to begin to biochemically characterize AIDS-KS cells. Three interrelated biochemical areas were evaluated: bioenergetic status (cellular growth characteristics), glutathione levels (cytoprotection and thiol maintenance), and catalase activity (degradation of H202). Comparison of the cellular bioenergetic profiles revealed that relative to human microvascular endothelial cells (HMECS), AIDS-KS cellspossessed a more glycolytic bioenergetic profile, and contained significantly lower levels of the high ener,g phosphates ATP, GTP, UTP, CTP, as well as NADPH. Further, relative to either normal dermal fibroblasts or HMECs, AIDS-KS cells possesseddecreased cytoprotective capabilities as shown by their significantly lower levels of both catalase and glutathione. Our results imply that decreased cytoprotection, in conjunction with subsequentROS-mediated cellular perturbations such as DNA mutations, may not only instigate the initial development of AIDS-KS lesions, but also facilitate KS lesional progression. DETECTION OF TN&, IL-l/z?, AND IL-6 mRNA IN ORAL KAPOSI’S SARCOMA USING IN SITU HYBRIDIZATION AND BIOTINYLATED OLICONUCLEOTIDE PROBES.

Regezi JA, Dekker NP, MacPhail LA. Department of Stomatology, University of California, San Francisco. Kaposi’s sarcoma is a heterogeneouspopulation of cells composedof not only endothelium-related spindle-shapedcells, but of also XIIIa+ dendrocytes and CD68+ macrophages.From cultures of Kaposi’s sarcoma cells, several tumor-derived cytokines have been identified that are hypothesized to be important in tumor proliferation. The purpose of this project was

778 Abstracts

ORAL SURGERY ORAL MEDICNE ORAL PATHOLOGY

Decemberi 994

to confirm the presence of these cytokines in tissue sections. In situ hybridization was done on formalinfixed, paraffin-embedded tissue sections using biotinylated ogligonucleotide probes complimentary to mRNA of cytokines, TNFa, IL-lp, and IL-6. Hybridized probes were detected with an antibiotin, streptavidin-biotin, alkaline phosphatase system. Standard irnmunohistochemistry was used to identify macrophages and dendrocytes in adjacent sections. Positive cytokine signals were seen in 15 of 18 tumors. Labeled cells ranged in number from few to numerous, and were located predominately in the peripheral portions of the tumors, although stained cells were evident throughout, as well as in adjacent connective tissue. Overlying basal keratinocytes were infrequently positive. Small (presuma ly early) Kaposi’s sarcomas had fewer positive cells per unit area than advanced lesions. By virtue of their intratumor and extratumor locations, the positively stained cells were felt to be macrophages or macrophage-related cells. This was also supported by comparison with immunohistochemically stained sections. The numerous CD68+ macrophages and XIIIa+ dendrocytes that showed no mRNA labeling, could have had undetectable low message levels, or they could have been producing other proteins. Also, many of these cells were likely involved in phagocytosis of the abundant hemosiderin and extravasated red cells found in these tumors. We believe that our results support the belief that TNFcu, IL- I@, and IL-6 assist in the progression of Kaposi’s sarcoma and that these cytokines are produced by cells with a macrophage phenotype. (Supported by ADS Clinka~ Research Grant $539709 20520.) INTRAORAL SQUAMOUS CELL CARCINOMA IN HIVSERO~~SIT~VE MALES: AN IM~U~QCYTOC~EMICAL, IN SITU HYBRIDIZATION AND CLI~IC~PAT~QLQGIC STUDY. Flaikz CA4, Hicks MJ, Nichols CM, Adler-

Storthz K. University of Texas Dental Branch, Bering Dental Clinic, Tex., Children’s Hospital, Baylor College of Medicine, Houston, Tex.

HTV infection is associated with an increased incidence of oral malignancies, however, intraoral squamous cell carcinoma (KCC) is not one of these. The purpose of this study was to characterize clinical and histologic features of ISCC ir, four HIV-seropositive males and to evaluate viral co-factors (HPV, HSV, EBV), proliferative indexes (PCNA), factors associated with invasion (Cathepsin-D) and oncogene products (P53, c-erb). Three homosexual/bisexuals and one injecting drug user (age, 35 to 5 1 years) with AIDS (mean, CD4 = 140) presented with painful oral lesions (duration, 8 to 48 months). Oral cancer

risk factors included heavy smoker (4/4), heavy alcohol use (3/4), and prior radiotherapy (l/4). Lesions varied from ulcers (2/4), fungating mass (l/4) to papillary erythroplakia ( l/4). Biopsies were obtained from each patient. High stringency in situ hybridization was performed using DNA probes to HPV (types 6/11; 16/l& 31/33/35) and to EBV. Immunscytochemical study for HSV, PCNA, Cathepsin-D, P53 and c-erb were performed (citrate-buffer, microwave technique). Three lesions were moderately to poorly differentiated; one was carcinoma in situ. Stage of disease at diagnosis was 11( l/4), III(2/4) and IV( l,/ 4). HPV was positive in three cases (types 16/l 8 [2/3], 6/l 1 [l/3]). HSV was positive in two cases; EBV in one case. C-erb was focally positive in one case. P53 was negative in all cases. Cathepsin-D was expressed in all cases and PCNA was expressed in 80% of tumor cells. Well-defined risk factors for malignancy play a prominent role in development of intraoral squamous cell carcinoma in this immunocompromised population. Interaction of co-factors (immune dysfunction, viral agents, cellular proliferative and invasive factors) with documented risk factors in malignant transformation may contribute to the development of oral squamous cell carcinoma in HIVinfected persons. ASSOCIATION OF ~53 EXPRESSION IN EARLY STAGE T-i ORAL CAVITY

WlTH SURVIVAL CANCER (OCC

McDonald JS, Pavelic ZP, Stambrook PJ, Wilson KM, Li Y-Q, Pavelic LJ, ~unck-~ikland E, Danilovic Z, Dacic S, Nguyen C, Cluckman JL. Departmen@ of Utofaryngology-Head and Aieck Surgery and Anatomy and Cell Biology, University of Cincinnati, Ohio, Otorhinolaryngology, Karolinska Hospital, Stockholm, Sweden, and Pathology, University of Zagreb, Croatia.

Generally Tl OCC is associated with excellent prognosis. However? in approximately 10% of patients these early cancers behave in an aggressive manner with poor prognosis. Clinical and histologic criteria, such as tumor thickness, pattern of invasion and histologic differentiation, are of limited value as prognostic indicators. Consequently, experimental focus has turned to the aberrant expression of oncogenes and tumor suppressor genes as potential prognostic factors. Of particular interest has been the potential role played by the ~53 tumor suppressor gene in the genesis and progression of several tumor types. Analysis of p53 protein with monoclonal antibodies (MAbs) is useful for estimating expression and distribution of mutated p53 protein at the cellular level. In a retrospective study we have assessed the presence or absence of ~53 protein in 82 patients who

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY volume 78, Nwmber 6

presented with Tl QCC by immunohistochemistry using the PAb1301 MAb (Oncogene Science, Inc.). Nuclear p53 staining of tumor cells was assessed before obtaining survival information, and all tumors with p53-reactive cells were scored as positive. This result was correlated with survival of these patients. Twenty-two tumors were deemed aggressive based on their propensity for regional or distant metastasis, or local aggressive recurrence at the primary site. Survival was expressed as the number of months from the date of primary surgery to the date of death if due to the malignancy. The Kaplan-Meier survival curve demonstrated that Tl lesions negative for p53 staining behaved less aggressively and were associated with a better prognosis than those positive for p53 (P > O..OOS).As we recently reported, there was no significant association between immunohistologic detection of p53 protein and survival among patients in late stage of the disease. Thus p53 accumulation appears to be particularly important in the early stages of OCC progression. This study is the first to report that ~5’3 accumulation in early OCC may identify a subgroup of patients with a propensity for a less aggressive course. Similar results showing an association between ~53 accumulation and poor prognosis in human lung and gastric cancers respectively have been reported by Quinlan et al. (Cancer Res 52:4323, 1992) and Martin et al. (Int J Cancer 150:359, 1992). The implications of these studies may lead to better prognostics and treatment modalities. IMMUNOHISTO(CHEMICAL LOCALIZATION OF PCNA, ~53, AND CYTOKERATINS IN ORAL DYSPLASIAS AND SQUAMOUS CELL CARCINOMAS. Singh B, Hall J,

Chandler F Jr. Medical College of Georgia, Augusta, Ga.

In the realms lof neoplasia the development, degree of cellular proliferation and differentiation of malignant tumors htive been considered of fundamental importance to assesstheir biological behavior. Therefore it was considered pertinent to examine the expression of: (11) proliferating cell nuclear antigen (PCNA-“Cyclin”); (2) p53 phosphoprotein, implicated to play an important role in cancer development and (3) cytokeraltins (CKs), the differentiation products of epithelial cells. For this purpose immunohistochemical techniques using monoclonal antibodies (Abs) were used on formalin-fixed, paraffin-embedded 5~ sections of oral dysplastic and malignant lesions. The application of anti-PCNA antibody (PC 10) revealed a sequentially proportional suprabasal increase in PCNA expression in mild (n = 5), moderate (n = lo), to severe dysplasias (n = 10). Many neoplastic cells showed reactivity in poorly dif-

Abstracts 779

ferentiated islands of squamous cell carcinomas (n = 15) whereas differentiating areas exhibited heterogenity with the keratin pearls labelling primarily in the peripheral cells. Nuclear and cytoplasmic antip53 (Abs. 1301 and D07) immunoreactivity of varying degree was present in 5 (n = 10) carcinomas, 2 (n = 10) severe dysplasias, 1 (n = 5) moderate dysplasia; and none in mild dysplasia, hyperplasia, or normal epithelium. CKs 3 and 13 (Ab CAM 5.2) activity was expressed in seven (n = 10) carcinomas with staining activity of poorly differentiated and peripheral cells of differentiating islands. Variable CK 14 activi%ty was observed in eight carcinomas and CK13 was primarily expressed in the differentiating cells. These studies suggest that accumulation of p53 phosphoprotein, an indicator of p53 gene mutation in overt neoplastic lesions coupled with proliferative potential shown by PCNA and an altered cytokeratin expressions are linked to the malignant states. DETECTION OF P53 MUTATIONS IN NORMAL, PREMALIGNANT, AND MALIGNANT ORAL EPITHELIAL LESIONS. Mao E-J, Oda D, Beckmann AM. Fred

Hutchinson Cancer Research Center and University of Washington, Seattle.

Oral squamous cell carcinoma is the most common malignancy in the oral cavity. Although the epidemiology of this tumor is well described, little is known about the molecular mechanisms involved in its development. Many reports have shown the expression of a mutated or phenotypically altered p53 tumor suppressor gene in a wide variety of human malignancies. Recently, several reports have demonstrated that either mutations or overexpression of p53 are a common occurrence in head and neck cancers. However, most of these reported mutations were found in tissue culture cells or by immunohistochemistry techniques. In the present study, a series of 40 paraffinembedded biopsies (including 6 normal tissues, 9 oral epithelial dysplasias, 7 in situ carcinomas, 10 welldifferentiated carcinomas, and 8 poorly differentiated carcinomas) were analyzed for point mutations in the p53 gene. For each biopsy the lesion was surgically separated by dissecting microscopy from its connective tissue, and both parts were analyzed individually. Exons 5-8 of the p53 gene were examined by the PCR-single stranded conformational polymorphism (SSCP-PCR) technique. Six of 34 (17.6%) biopsies were found to have: mutations at exons 6 or 8 whereas no mutations were found in the corresponding connective tissues. These mutations were found in 44.4% of the biopsies with dysplasia, 14% of in situ carcinoma, and 10% of well-differentiated carcinomas. One normal biopsy from a heavy smoker was shown

780 Abstracts to have a mutation in exon 6. These preliminary results suggest that mutations in the ~53 gene appear to contribute to the early stage of development of oral malignancies. ~53 point mutations might be used as a diagnostic marker for potential malignant change in the early oral malignancy. Our studies of the relationship between ~53 mutations and tobacco and alcohol use will be reported. The precise mutational spectrum will be determined through direct genomic sequencing after PCR amplification. P53 EXPRESSION IN EPITHELIAL NE~~LASM§ OF THE ECK. Copete MA, Gilchrist EP, Murrah

VA. The University of Texas Health Science Center at San Antonio, San Antonio. The tumor suppressor gene, ~53, is a significant factor in the regulation of cell proliferation and is also thought to play a role in carcinogenesis of the head and neck region. Mutation of the gene or the complexing of the protein with viral gene products can induce an aberrant overexpression of the p53 protein that can be identified by immunocytochemistry techniques. Delineation of the range of overexpression of p53 in carcinomas of the head and neck may provide prognostic, and therapeutic implications and greater insight into the process of carcinogenesis. The purpose of the present investigation was to characterize p53 overexpression in a series of head and neck neoplasms accessioned over a 5-year period by the Oral, Head and Neck Pathology laboratory at the University of Texas Health Science Center and Medical Center Hospital, San Antonio, Texas. One hundred cases of paraffin-embedded epithelial neoplasms were immunostained by the avidin-biotin technique with the monoclonal antibody NCLDO7 anti-p53 protein (Vector Laboratories, Burlingame, Calif.); 60/ 100 (60%) of all cases showed positive staining, including 49/85 (57.6%) of carcinomas, 3/3 (100%) of carcinomas in situ and 2/5 (40%) of epithelial dysplasias. Five of seven (71.4%) benign papillary neoplasms were also positive. The results of this investigation provide additional evidence that ~53 mutation is a frequent occurrence in head and neck neoplasia. Positive staining of benign lesions and intraepithelial precursors of squamous cell carcinoma supports the hypothesis that ~53 mutation occurs as an early event in carcinogenesis. The finding of focal ~53 overexpression in benign papillary lesions suggests the caveat that such lesions may have greater potential for malignant transformation than is usually assumed by clinicians. Future work will focus on the relationship between ~53 and human papillomavirus.

ORAL SURGERY QRAL MEDlCiNE ORAL PATHOLOGY

December 1994

APPLICATION OF COMBINED IN SI TION AND IMMUN~C~T~CHEM~STR OF KERATIN GENE EXPRESSION 1N 0

L, Morgan P. Department of Oral Medicine and Pathology, UMDS (Guy’s Campus), London, U.K. Oral squamous cell carcinomas (SCCs) have been reported to express simple epithelial keratins (M) 8 and K18 although these proteins are present in no more than trace amounts in normal oral epithelia. Little is known about the way in which K8 and EL18 synthesis is switched on in malignancy so, to explore keratin gene expression in vivo, we have compared the distribution of mRNA by in situ hybridization and protein by immunocytochemistry for K8 and K18 in a series of normal, dysplastic, and malignant oral epithelia (N = 28). In normal epithelia mRNAs for these keratins were present mainly in basal cells, but corresponding sections were negative for the respective proteins. In severe dysplasia there was irregular extension of K8 and K 18 mRNAs throughout the epithelial thickness in all cases, K8 and K18 proteins being expressed in more than half the cases. Oral SCCs expressed K8 and K18 mRNAs homogeneously in all cases as well as showing strong reactivity for both keratin proteins. These results provide evidence for the posttranscriptional regulation of Kg and K18 expression in normal oral epithelia whereas the presence of their proteins in dysplastic and malignant oral epithelia suggests that during malignant transformation oral epithelial cells are released from a posttranscriptional block on Kg and K18 translation. Alternatively, rapid degradation of K8 and Kl8 protein might be occurring in normal epithelia, a process that is suppressed in cases of dysplasia and malignancy. The combined study of mRNA and protein in nearby sections of oral epithelia has shown that the expression of transcript does not always parallel that of the respective protein and provides unique information on keratin gene expression in histopathologic specimens. MYOEPITHELIAL CELL: ANOTHER ~OSSlB~ PROGENYTOR CELL FOR NEOPLASTIC IN~UCT~Q VARY GLAND TUMQRS? Burgess K, Dardick I, Bur-

ford-Mason A, MacKay A. Facmlty of Dentistry and Department of Pathology, University of Toronto, Toronto, Ontario, Canada. Despite limited evidence, salivary gland myoepithelial cells (MEG) are said to be differentiated cells with little or no capacity to replicate and presumably require development from stem cells. However, other fully differentiated cells have recently been shown to have a regenerative potential in rat (Mod Pathol 6:8OA, 1993) and human (Oral a 1OHSurg 76:307,

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

Abstracts 781

Volume 78, Number 6

1993) isglands. ‘This study investigated the proliferative potential of MEC using an antibody to proliferating cell nuclear antigen (PCNA, PClO) and a rat model with clamping of the parotid duct for 7 days to induce parenchymal atrophy and then released to determine cycling cells during parotid regeneration. Rats were sacrificed at time points during atrophy and regeneration phases, and the number of MEC with PCNA positive and negative nuclei counted. Double immunohistochemical staining labeled cycling nuclei for PCNA and cytoplasmic muscle-specific actin (antiblody HHF35) for MEC. The results show that MEC were induced to cycle in the atrophy phase of this model. Baseline proliferative rates of MEC were 1% to 2% in both the resting and fully regenerated gland, similar to rates for other major cell types in the norma. rat gland. Maximal MEC proliferative rates of 23% occurre,d at day 5 during the atrophy phase (Fig. 1). Rates during the regenerative phase were not significantly different than baseline levels. Comparison of this data to proliferation rates for acinar, intercalated and striated duct cells show that the peak proliferation rate of MECs is higher and earlier than the other types of cells during gland atrophy. Similarities of rat and human parotid gland and the proliferat.ive capacity of MEC indicates that these specialized cells must be considered potential progenitor cells of human salivary gland tumours. ANCIOCENESISI NoMAs AND

IN ORAL

SQUAMOUS CELL CARCIBY ~ETlN0lc ACID. k2-

us INHIBITION

gen M, Polverini P, Bouck N. Northwestern University, Chicago, Ill., IJniversity of Michigan, Ann Arbor.

Oral squamous cell carcinoma (SCC) is an aggressive epithelial cell malignancy with a poor 5-year survival rate. Patient long-term survival is further complicated by the high rate of second primary SCC development. Retinoic acid (RA) is clinically effective at controlling tlhedevelopment of new primary lesions. However, the mechanisms that underlie its chemopreventive actions are unclear. Like all solid tumors, SCC must stimulate neovascularization to grow and metastasize. To determine if RA modulation of angiogenesis contributes to this activity, angiogenic tumor cell lines derived from the hamster buccal pouch and human oral keratinocytes were treated with all-trans RA (lo-6 M) for 7 days. Conditioned media (CM) were collected from treated cells, concentrated, and assayed for their ability to stimulate or to inhibit angiogenesis in both in vitro endothelial cell migrations and in vivo rat cornea assays. The treatment of hamster and human tumor cells with RA re-

sulted in a switch from an angiogenic to an antiangiogenic phenotype. In addition, RA was found to act directly on endothelial cells to inhibit their ability to migrate towards hamster and human tumor cell CM. Thus, RA influences angiogenesis in two ways: (1) by causing angiogenic keratinocytes to switch from an angiogenic to an angioinhibitory phenotype and (2) by making endothelial cells refractory to angiogenic stimuli. Both of these activities may contribute to successful use of RA as a chemopreventive agent. ORAL CANDIDIASIS IN HIV-INFECTED PATIENTS: HISTOPATHOLOGY AND ROLE OF CELLULAR IMMUNITY.

Ficarra G, Romagnoli P, Pimpinelli N, Rubino I, Mori 44, Eversole R. University of Florence and USL 1O/D, Italy, University of California, Los Angeles.

Oral candidiasis (OC) is a common infection in HIV+ patients. Main clinical forms are pseudomembranous (P), erythematous (E) and angular cheilitis. There is little information on the histologic changes and role of immune cells involved in the pathogenesis of OC in HIV-t patients. Fifteen patients with OC were studied with a combination of smears, tissue biopsy, EM, PAS, immunohistochemistry and culture; 13 were men and 2 women. Type of lesion was: E, 11 cases (6 dorsum tongue, 3 palate, and 2 vestibular mucosa) and P, 4 (1 tongue and 2 vestibular mucosa). Common features were parakeratosis, hyperplasia, inflammatory infiltrate (lymphocytes) in both epithelium and lamina propria and necrotic debris. Neutrophils were rarely seen. PAS stain on smears demonstrated pseudohyphae and blastospores in 7 of 7 cases (100%). PAS stain on tissue specimens was positive in 7 of 9 cases (two biopsy of the E form were negative). Candida albicans was isolated in 14 cases, Analysis of the immune cell infiltrate showed that this was richer in cells and included Langerhans’ cells better differentiated, in cases of E than P candidiasis. In all cases infiltrating lymphocyte were almost exclusively CD8+ cells, independently of the number of circulating CD4+ lymphocytes. These results hint to a defect of local immune responses in these patients; this defect appears severe in cases of P candidiasis. LONG-TERM OCCLUSIVE STEROID THERAPY FOR THE TREATMENT OF GINCIVAL MANIFESTATIONS OF MUCOCUTANEOUS DISEASES. Warner B, WolfD, Lynch

D. LJniversity of Texas, Houston and University of Tennessee,Memphis.

Ciingival manifestations of mucocutaneous diseases are a source of significant morbidity and interfere with personal oral hygiene. Long-term systemic steroid therapy is limited because of side effects, and

782

Abstracts

topical steroids have a limited duration of action. Topical corticosteroids and occlusive vinyl appliances were used to treat 78 patients with gingival manifestations of mucocutaneous diseases for 6 to 71 months. Patients were predominantly female (94%) with a mean age of 57.3 years and had biopsy-confirmed lichen planus (n = 64), pemphigoid (n = 13), and pemphigus (n = I). Gingival signs and symptoms had been present for over 1 year in 42% of patients. Vinyl appliances that cover the teeth and gingiva were constructed. Patients placed a thin film of Lidex gel or Temovate ointment on the tissue-bearing surfaces of the appliances and wore them nightly. All patients had a significant decrease in gingival erythema, ulceration, and pain within 1 month and reported increased ease of oral hygiene procedures. No steroid side effects or temporomandibular joint problems were reported or detected. Patients subsequently self-titrated their’ treatment, based on the presence or absence of gingival signs and symptoms, and were followed at least semi-annually. Occlusive steroid therapy appea,rs to be a cost-effective, safe, and effective long-term treatment modality for gingival manifestations of mucocutaneous diseases. THERAPEUTIC AND MICR~~IOL~~IC CONSIDERATIONS IN THE TREATMENT OF DES SKINS OF THE GINCIVA. Parker ~3; Weathers D. Em-

ory University, Atlanta, Ga.

Desquamative lesions of the gingiva represent a relatively common oral presentation of several mucocutaneous diseases. Recent advances in the immunopathologic characterization of desquamative processes have enabled clinicians to more definitively diagnose these lesions and direct therapy toward a specific disease process. Although the majority of diseases that can present as desquamative gingivitis are thought to be primarily autoimmune or immune dysfunctional in cause, they often occur in concert with existing periodontal inflammation that is bacterial in cause. The purpose of this study is twofold; first, to evaluate the effectiveness of a protocol for the diagnosis and treatment of desquamative gingival lesions, and second, to examine the periodontal microflora of desquamative gingivitis patients and the effect of periodontal pathogen-directed antimicrobial therapy on the course of desquamative lesions. A total of 14 patients who presented with desquamative gingival lesions were enrolled in the study, 12 females and 2 males. Each patient received the following diagnostic procedures; cytology smear

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

December1994

for fungal organisms, gingival biopsy for routine hematoxylin and eosin staining, gingival biopsy for direct immunofluorescence, and bacterial culture for periodontal pathogens. Following initial examination, the patients were treated with antifungal medication if indicated, then treated with antimicrobial therapy as determined by microbiologic culture and antibiotic sensitivity. On completion of antimicrobial therapy, the patients were recultured to ensure eradication of periodontal pathogens and placed on a regimen of 5 mg/ml triamcinolone oral rinse and 0.05% fluocinonide cream. demonstrated S/ 14 patients diagn lichen planus, 4/14 as benign mucous membrane pemphigoid, whereas 2/14 patients were not diagnostically conclusive. Significant elevations of periodontal pathogens were found in 6/14 patients. Slight improvement in desquamative lesions was seen after antimicrobial therapy in most patients. Significant resolution of desquamative lesions was observed after corticosteroid therapy in 9/ 11 patients followed for over 4 months. The findings of the study describe an effective protocol for the diagnosis and treatment of desquamative lesions of the gingiva and introduce a possible synergistic role of antimicrobial and immune suppressive therapy in the treatment of these lesions. AN UPDATE ON THE ORAL AND MAXIL~OFAC~A~ ASPECTS OF CHRONIC FATIGUE AND IM FUNCTION SYNDROME (CHRONIC FATGUE SYNDROME). Glass R. University of Oklahoma, Okla-

homa City.

Chronic fatigue and immune dysfunction syndrome (CFIDS) or chronic fatigue syndrome (CFS) has been defined by the Centers for Disease Control and Prevention as a condition that has both major and minor surveillance criteria but which has a central manifestation, fatigue that decreases activity by 50% for more than 6 months. To date, there are no definitive tests for the diagnosis of this condition. Previous studies of the oral manifestations of CFIDS have shown that the oral and maxiilofacial area is often involved in the condition (AAOP Abs., 1993). The purpose of this paper is as an update of more recent oral and maxillofacial findings on patients who have CFIDS. Special attention will be paid to the problems of temperomandibular dysfunction, salivary gland dysfunction, metal toxicity, inappropriate response to root canal therapy, and possible associations between CFIDS and neuralgia-inducing cavitational osteonecrosis (NICO). The

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Volume78, Number 6

role of a labial salivary gland biopsy as a possible diagnostm test for CFIDS will also be discussed. MALIGNANT MELANOMA MASQUERADING AS A MYOFIBROSARCOMA. Jones A, Baughman R, Mul-

lins D, Berm 13, Tillery Jr. D. University of Florida, Gainesville, and Longwood.

Malignant spindle-cell tumors present difficult diagnostic dilemmas in the oral cavity. A 62-year-old white woman came to an oral and maxillofacial surgeon for evaluation of a recurrent exuberant growth of 2 months dluration involving the left hard palate. Microscopic e.xamination demonstrated a spindle-cell neoplasm composed of elongated blunt-ended to tapered hyperchromatic nuclei arranged in an illdefined fascicular pattern. The tumor cells demonstratied slight pleomorphism and scattered mitotic figures. Immunohistochemistry revealed cytoplasmic positivity for muscle specific actin, vimentin, and focal s,-100 protein. The tumor cells were negative for AEl/AE3, HMB 45, and desmin. Differential diag-

Abstracts 783

nosis included diesmoplastic melanoma, neurotropic melanoma, and atypical spindle-cell neoplasm with myofibroblastic differentiation. Electron microscopy (EM) revealed relatively undifferentiated spindle cells with mitochondria, rough endoplasmic reticulum, and microfilaments. Intercellular bridges and basal lamina were not observed in the tumor cells. The tumor was tentatively diagnosed as a myofibrosarcoma in light of positive actin and vimentin and the absence of melanosomes on EM. Radiographic evaluation revealed ,extensive destruction of the left posterior hard palate, alveolar ridge, and floor of the maxillary sinus. Nodal enlargement was evident in the left neck. Radical neck dissection showed a biphasic spindle-cell tumor with focal epithelioid areas and positive staining for s-100 protein and HMB 45. The tumor was definitely diagnosed as a primary mucosal melanoma. This case illustrates the pitfalls associated with the diagnosis of intraoral spindle-cell neoplasms. The clinical, radiographic, and microscopic features of this unusual tumor will be discussed.