Original research study The deleterious nature of the invasive front - - PDF document

SLIDE 1

Page 1 of 6 Competjng interests: none declared. Confmict of interests: none declared. All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure.

Original research study

For citation purposes: Upile T, Jerjes W, Johal O, Lew-Gor S, Sudhoff H. The deleterious nature of the invasive front and dysplasia at margin in the long-term outcome from surgical treatment of squamous cell carcinoma of the head and neck. Head Neck Oncol. 2012 Oct 31;4(3):72.

Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)

Abstract

Introduction The characteristic of the cells at the leading edge of malignancy may have a deleterious prognostic significance. Materials and methods A 10-year retrospective analysis was performed, data from 282 patients were reviewed and a detailed patho- logical review was undertaken. The data was entered into a database, which was independently validated for accuracy. Individuals recorded were monitored for five years from the initial surgical insult. Results The tumour–nodes–metastasis classi- fication was validated in the follow- up study as a prognostic indicator. Transfusion had an adverse effect on survival and chance of recurrence. Dysplasia at margin, clearance (mm)

• f resection (i.e. surgical margin) and

the nature of the invasive tumour front at the margin all had adverse effects upon the likelihood of cancer recurrence. Discussion The nature of the invasive front should be considered in any prognos- tic discussion and also when plan- ning surgery. Transfusion triggers should be revised to avoid transfusion

• f blood products (which have cancer

growth promoting properties). The survival rates after recurrence of

The deleterious nature of the invasive front and dysplasia at margin in the long-term outcome from surgical treatment of squamous cell carcinoma of the head and neck

T Upile1,2*, W Jerjes3, O Johal1, S Lew-Gor2, H Sudhoff2

disease is poor, in part, due to the en- trenched adaptive behaviours of the residual tumour cells which manifest several areas of resilience (i.e. radio- therapy, chemotherapy) and which may have already invaded local im- portant structures (making them resilient to surgery). To improve the overall survival rates, we must address the surgical margin from the onset before consid- ering adjunctive treatments which alter local vasculature (blood and lymphatic) and tumour spread pat-

• terns. Intraoperative margin analy-

sis is important to address regions

• f concern before wound healing be-

comes entrenched and the chance to take corrective action is missed.

Introduction

The characteristic of the cells at the leading edge of malignancy may have a deleterious prognostic significance. Unlike the centre of cancer which may have a relatively poor blood sup- ply, resulting in an anoxic environ- ment and low metabolic activity, the invasive front of a tumour is bathed in the host milieu of oxygen and nu- trients from both normal vasculature and the co-opted blood supply, en- abling it to grow actively and perva-

• sively. The invasive front of cancers is

also the battle ground where the often losing host defences (extracellular matrix and immune response) fail to destroy or limit the disease’s prog-

• ress. The extent of the host response

may well be indicated by the very nature of this edge of malignancy. In a well-developed host response, the edge of the lesion may well be en- capsulated and the tumour limited by a fibro-immune reaction, whilst in more aggressive cancers this host response may be inadequate and the host defences may have several breaches from where the tumour gains privileged access to the rest of the body. Another important consid- eration is to not be limited to two- dimensional thinking because of our habituation towards viewing simple histological images from sectional

• analysis. It must be realised that the

tumour exists as a three-dimensional entity with potentially viable chains

• f cells along all its borders ready to

invade1–3. The three-dimensional nature of the invasive border of a cancer may be appreciated in the Byrne classifi- cation system. The discohesive edge may not represent individual cells, but the infield view of some con- nected cells out of the plane of the histological section. In contrast, a co- hesive front may represent a strong immuno-fibrous host response and a poorer adaptive ability of the tumour to overcome this1–3. The nature of the invasive edge of a cancer has very important surgical

• ramifications. The often uncertain

edge of the tumour leads to a survival margin of uncertainty which results in more adjacent normal tissue being excised to encompass cancer clear- ance2–4. This should be appreciated by both basic scientists and practic- ing clinicians (surgeons5, radiation

• ncologists) because there is always

a finite probability of residual tumour growth manifesting later as a ‘recur- rence’, the clones of which may have a degree of developed radio resis-

• tance. Objectively the primary cura-

tive treatment of head and neck squamous cell carcinoma is complete

* Corresponding author Email: mrtsupile@yahoo.co.uk

1

Department of Otorhinolaryngology, University

• f Bochum, Germany

2

Department of Otolaryngology, Brighton and Sussex University NHS Trust, Brighton, UK

3

Leeds Institute of Molecular Medicine, School

• f Medicine, University of Leeds, Leeds, UK

SLIDE 2

For citation purposes: Upile T, Jerjes W, Johal O, Lew-Gor S, Sudhoff H. The deleterious nature of the invasive front and dysplasia at margin in the long-term outcome from surgical treatment of squamous cell carcinoma of the head and neck. Head Neck Oncol. 2012 Oct 31;4(3):72. Page 2 of 6 Competjng interests: none declared. Confmict of interests: none declared. All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure.

Original research study

Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)

surgical ablation with clear margins evident on multiple histological sec-

• tions6. Radiotherapy after surgery

does little to confer a significant sur- vival improvement when a margin is involved. It is better to get things right the first time by appreciating the complex three-dimensional na- ture of cancer spread and the current limitations of intraoperative surgical excision guidance, which is still at a macroscopic level, whilst the disease infiltrates on a microscopic level7–11. The aim of the retrospective analy- sis was to investigate the factors af- fecting patient survival in head and neck carcinoma.

Materials and methods

A 10-year retrospective analysis was

• undertaken. Identical ‘intent to treat’

protocols were used to treat these

• patients. The study protocol was

approved by the committee of the ethics for human research. Inclusion criteria included patients diagnosed with squamous cell carcinoma of the aerodigestive tract, complete patient episode details (clinical, surgical, ra- diotherapy and oncology) and follow- up for five years or until death. While exclusion criteria were applied when having incomplete medical records

• r loss to follow-up.

Using these criteria, 282 sets of medical records were identified. Data from these records were reviewed and a detailed pathological review was undertaken; the data was en- tered upon a database which was in- dependently validated for accuracy. Individuals recorded were followed for five years from the initial surgical

• insult. The database was validated by

another medical practitioner before anonymisation and encryption. All patients were operated upon with the primary objective of achiev- ing a macroscopic clearance of 0.5– 1.0 cm. Post-operative radiotherapy was given according to our standard protocols, if applicable. Statistical analysis The database was statistically anal- ysed by an independent UK statisti-

• cian. Regular briefing and debriefing

meetings were held to explain possi- ble hypotheses and review how they should be tested. Furthermore, in- terim analysis was used to modify hy- potheses to try and refine how the data was interrogated to provide meaningful results.

Results

Demographic details of the 282 pa- tients presenting for surgical treatment with head and neck squamous cell carcinoma are illustrated in Table 1. The demographics of our cohort show the typical sex and age distribu- tion which is as expected. The Byrne classification was used to stratify the nature of the infiltrating edge of the Table 1 Demographic details of the 282 patjents presentjng for surgical treatment with head and neck squamous cell carcinoma.* UK socio-economic class classifjed from 1 (high) to 5 (deprived) Detail Index Detail Index Gender 90 female:192 male Clearance at the superfjcial margin 3.95 ± 2.17 mm Age 65.49 ± 15.24 Clearance at the deep margin 3.87 ± 2.02 mm Family history 90 Dysplasia at margin 52 Previous surgery 168 Type of neck dissectjon 132 (unilateral); 44 (bilateral) Personal cancer history 83 Hard tjssue resectjon 117 Heavy smoker 254 Length of surgery (hours) 7.89 ± 3.8 Ex-heavy smoker 159 Previous chemo-radiotherapy 37 Heavy alcohol intake 100% Local recurrence 52 Betel quid intake 14 Distant metastases 22 Dietjng 32 on diet Synchronous tumours 6 Socio-economic class* 4.57 ± 1.64 Tracheotomy 108 Depth of tumour invasion 9.47 ± 6.45 mm MRSA status at 6 (admission); 16 (discharge) Extracapsular invasion of LN 5 (bilateral) Blood product transfusion 61 Vascular invasion 41 Days in high dependency 1.84 ± 1.57 Neural invasion 15 Follow-up (to date) 40.75 ± 13.13 months Bone/cartjlage invasion 52 3 year survival 0.91 ± 0.28 Severe dysplasia in fjeld 63 5 year survival 0.87 ± 0.33 Discohesive patuern of invasion 113 Survival from fjrst diagnosis (to date) 872.7 ± 328.2 days

SLIDE 3

Page 3 of 6 Competjng interests: none declared. Confmict of interests: none declared. All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure. For citation purposes: Upile T, Jerjes W, Johal O, Lew-Gor S, Sudhoff H. The deleterious nature of the invasive front and dysplasia at margin in the long-term outcome from surgical treatment of squamous cell carcinoma of the head and neck. Head Neck Oncol. 2012 Oct 31;4(3):72.

Original research study

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• f 0.44 and N+ disease (hazard ratio,

0.36) also showed significance (p < 0.05) Gehan-Breslow-Wilcoxon test. The group stage was also signifi- cantly correlated to survival (p < 0.001). Local cancer recurrence was asso- ciated with poor survival (p < 0.001) and was significantly (p < 0.001) associated with previous surgery, clinical TNM, methicillin-resistant Staphylococcus aureus (MRSA) (on admission or discharge), length of surgery, depth of tumour invasion and its clearance both superficial (mucosal) and deep (soft tissue) mar- gins, the need for a tracheostomy, total days in hospital post-operatively, pathological TNM and death from cancer. Local recurrence was significantly associated with previous cancer his- tory (p < 0.01) and dysplasia at the margin of resection (p < 0.05; Gehan- Breslow-Wilcoxon test with a hazard ratio of 0.418). Recurrence was significantly [p < 0.005 Log rank (Mantel-Cox) test] associated with le- sions which had a discohesive front

• r invasive front rather than this with

a cohesive or non-invasive front. More infiltrative cancers will have a more advanced clinical stage, will take longer to remove and have a higher frequency of positive deep margins in the soft tissues with the patient re- quiring a longer post-operative hos- pital stay and often supplementary modalities such as radiotherapy in an attempt to salvage the margin

• r chemotherapy to palliate the pa-

tient for untreatable recurrence. Recurrence is associated with poor prognosis and reduced overall sur-

• vival. Semantically, the slowly grow-

ing residual disease which becomes manifest is often termed a recurrence by the no novitiate, whilst it really is really residual disease left in an irra- diated field leaving little room for successful treatment. The significant association of dysplasia at the margin

• f surgical resection with recurrence

may represent true recurrence or hence, the decent three and five year survival figures (Figures 5–8). The tumour–nodes–metastasis (TNM) system was validated as the prognostic measure T stage (both clinical and pathological) showed significance (p < 0.01) Log rank (Mantel-Cox) test with hazard ratio

• f 0.43); N stage (both clinical and

pathological) showed hazard ratio cancer which was informed by dys- plasia at the margin and sub-mucosal extensions (Figures 1–4). There was a slight increase in ton- sillar and tongue base tumours in the younger cohort, presumably attribut- able to early human papilloma virus

• infection. The series appear weighted

towards earlier and less advanced

• ral and oropharyngeal tumours;

Figure 1: This histological image il- lustrates severe dysplasia with a chronic inflammatory infiltrate be- tween the stroma and dysplastic epi- thelium (50× H&E). Note the layers

• f keratin, ‘keratosis’, but with the

pre servation of the basement mem-

• brane. The basal cell layer has ex-

panded to almost entirely populate the epithelial depth. Figure 2: This histological image il- lustrates squamous cell carcinoma at the sub-mucosal margin (100× H&E). Figure 3: This histological image il- lustrates a discohesive or invasive front from a poorly differentiated squamous cell carcinoma (bottom right). There is no obvious distinction between normal tissue and the in- vading nadirs of cancer (25× H&E). Figure 4: This histological image il- lustrates a clear demarcation be- tween tumour (bottom right) and surrounding tissue manifest as a co- hesive tumour margin (25× H&E).

SLIDE 4

For citation purposes: Upile T, Jerjes W, Johal O, Lew-Gor S, Sudhoff H. The deleterious nature of the invasive front and dysplasia at margin in the long-term outcome from surgical treatment of squamous cell carcinoma of the head and neck. Head Neck Oncol. 2012 Oct 31;4(3):72. Page 4 of 6 Competjng interests: none declared. Confmict of interests: none declared. All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure.

Original research study

Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)

from the local immune response. Unfortunately, post-operative radio- therapy does little to truly salvage an affected margin because survival tends to be worse if the lesion was completely removed initially with a clear margin of resection in the first instance; however, these patients and their physicians have little choice. The effects of transfusion delivered facilitators of tumour growth have been previously discussed as have their effects upon isolated cancer cell growth12–16. It may be assumed that in lesions with a cohesive front, it may be easier to surgically encapsulate a lesion with a closer margin of safety4 with-

• ut leaving residual tumour that will

manifest as a ‘recurrence’ in the full- ness of time. However, in tumours that have a discohesive front, this may not be so simple and a greater margin (of safety) may have to be ex- cised to achieve surgical ablation. As stated previously, in these cases, cells may often be left captive within the fibrous scar and may become dor- mant due to the nature of wound healing; however, discohesive cancer cells may also escape this reaction and later flourish. In the head and neck, this has important surgical, functional and survival ramifications since tissue volume is often at a pre- mium in these locations with very little room for error. Furthermore, the implication is that in a tumour with a discohesive edge abutting a vital structure, there may be a high chance of recurrence because the said structure is not re-

• moved. Our decision making is modi-

fied by the fact that some normal tissue structure provides a tempo- rary barrier to tumour expansion un- til the tumour cell progeny gain the iterative adaptive ability to secrete the appropriate extracellular matrix break down and motility factors. It cannot be assumed that the edge

• f a tumour is uniform in its cohesive

and discohesive nature since this appears more to be a function of Figure 5: The effect of transfusion of leukocyte depleted packed red blood cells upon survival (in months) in 282 patients with head and neck squamous cell carcinoma treated with surgery.

100 Survival (%) 80 60 40 20 40 Months 60 80 No transfusion Transfusion 110 100 Recurrence (%) 90 70 60 80 50 20 40 Months 60 80 <5 mm clearance >5 mm clearance

Figure 6: Recurrence proportions and mucosal clearance (superficial surgical margin) of 5 mm or more in 282 patients with head and neck squamous cell carcinoma treated with surgical resection. Unlike a survival curve, this analysis shows that there is less recurrence with a bigger surgical margin. actually in situ de novo disease in an ‘unstable field’ which has been se- lected out by bystander exposure to previous treatment modalities to be resistant to further similar therapies. In reality, these arguments are only semantic since the patient is still left in a difficult therapeutic position with little room for maneuver.

Discussion

The compete assessment of the surgi- cal margins at the time of resection with

• bjective

confirmation

• f

complete removal of both tumour and liable field is most likely to be as- sociated with long-term survival. This is an ideal that may not be often achieved, but the adverse conse- quences of minimal margin failure are often concealed by the ‘two- edged’ effect of scar formation; this serves not only to devitalise potential tumour seeds (making some dor- mant for later activation) but also to potentially shelter cancerous seeds

SLIDE 5

Page 5 of 6 Competjng interests: none declared. Confmict of interests: none declared. All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure. For citation purposes: Upile T, Jerjes W, Johal O, Lew-Gor S, Sudhoff H. The deleterious nature of the invasive front and dysplasia at margin in the long-term outcome from surgical treatment of squamous cell carcinoma of the head and neck. Head Neck Oncol. 2012 Oct 31;4(3):72.

Original research study

Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)

several areas of resilience (e.g. radio- therapy, chemotherapy) and which may have already invaded local im- portant structures, making them sur- gery resilient1. To improve overall survival rates, we must address the surgical margin4,20 from the onset before adjunctive treatments which alter local vasculature (blood and lymphatic) and tumour spread pat-

• terns. Intraoperative margin analysis

is important to address regions of concern before wound healing be- comes entrenched and the chance take corrective action is missed. The future Optically directed measurements (e.g. microendoscopically, elastic scatter- ing spectrographically or Raman spectroscopically) of tissue factors, such as Vegf expression or oxygen levels within the tumour and its inva- sive front, would help show if hypoxia itself is a stimulus for tumour growth and an independent factor in radio- therapy resistance. For more immediate information it may be possible to consider optical diagnostic techniques5,21–25 such as laser capture microdissection, which harvests viable cells from the main tumour, its invasive front and lym- phatic metastases (including extra- capsular spread) for rapid micro array or proteomic analysis. It would also be useful to grow tu- mour cell lines from bulk of tumour, invasive front and metastases to al- low molecular biological comparison to assess the efficacy of chemical re- agents during drug development. Particular interesting features to determine would be the expression

• f factors such as matrix metallo-

proteinase 1–926–28 at invasive front, micro-arrays of cells (to look for ge- netic switches) and oxygen concen- trations (hypoxia).

Abbreviations list

MRSA, methicillin-resistant Staphylococcus aureus; TNM, tumour– nodes–metastasis. in their dormancy or non-progressive until senescence or breach in the lim- iting factors17. This may occur through local trauma or wound heal- ing enriching the local vasculature and spilling growth promoters14–16,18,19 within the micro-environment that are utilised by the tumour. The survival rates after recurrence

• f disease is poor, in part, due to the

entrenched adaptive behaviours of the residual tumour cells which manifest the local microenvironment17 of the host tumour interface across its en- tire three-dimensional boundaries. Discohesion probably manifests at specific points of host protection breakdown. We are fortunate that in the many cases of theoretical margin breach, recurrence may not manifest because

• f the entrapment of a ‘limited’ num-

ber of tumour cells in scar tissue in a hypoxic environment, which results

95 85 75 65 Recurrence (%) 20 40 Months 60 80 <5 mm clearance >5 mm clearance

Figure 7: Recurrence proportions and deep clearance (surgical margin) of 5 mm or more in 282 patients with head and neck squamous cell carcinoma treated with surgical resection. Unlike a survival curve, this analysis shows that there is less recurrence with a bigger surgical margin.

60 70 80 90 100 20 40 60 80 Non-invasive (cohesive) front Invasive (discohesive) front Months Survival (%)

Figure 8: The effect of an invasive or discohesive front (Byrne 3/4) and non-invasive or cohesive front (Byrne 1/2) on the survival of patients having recurrence.

SLIDE 6

For citation purposes: Upile T, Jerjes W, Johal O, Lew-Gor S, Sudhoff H. The deleterious nature of the invasive front and dysplasia at margin in the long-term outcome from surgical treatment of squamous cell carcinoma of the head and neck. Head Neck Oncol. 2012 Oct 31;4(3):72. Page 6 of 6 Competjng interests: none declared. Confmict of interests: none declared. All authors contributed to the conceptjon, design, and preparatjon of the manuscript, as well as read and approved the fjnal manuscript. All authors abide by the Associatjon for Medical Ethics (AME) ethical rules of disclosure.

Original research study

Licensee OA Publishing London 2012. Creative Commons Attribution License (CC-BY)

consequences of transfusion in head & neck squamous cell carcinoma: an in vitro

• study. Head Neck Oncol. 2012 May;

4:22.

• 20. Songra AK, Ng SY, Farthing P,

Hutchison IL, Bradley PF. Observation of tumour thickness and resection margin at surgical excision of primary oral squa- mous cell carcinoma—assessment by

• ultrasound. Int J Oral Maxillofac Surg.

2006 Apr;35(4):324–31.

• 21. Upile T, Jerjes W, El Maaytah M,

Hopper C, Searle A, Wright A. Direct mi- crovascular monitoring of a free autolo- gous jejunal flap using microendoscopy: a case report. BMC Ear Nose Throat Disord. 2006 Sep;6:14.

• 22. Upile T, Jerjes W, Mahil J, Hopper C,

Sudhoff H. The use of optical technology to monitor the antiangiogenic effects of gefitinib treatment for advanced head and neck squamous cell carcinoma: a brief report. Lasers Med Sci. 2012 Jan; 27(1):257–60.

• 23. Upile T, Jerjes W, Radhi H, Mahil J, Rao

A, Hopper C. Elastic scattering spectros- copy in assessing skin lesions: an “in vivo”

• study. Photodiagnosis Photodyn Ther.

2012 Jun;9(2):132–41.

• 24. Upile T, Jerjes W, Sterenborg HJ,

El-Naggar AK, Sandison A, Witjes MJ, et al. Head & neck optical diagnostics: vision of the future of surgery. Head Neck Oncol. 2009 Jul;1:25.

• 25. Upile T, Jerjes WK, Sterenborg HJ,

Wong BJ, El-Naggar AK, Ilgner JF, et al. At the frontiers of surgery: review. Head Neck Oncol. 2011 Feb;3(1):7.

• 26. Sterz CM, Kulle C, Dakic B, Makarova G,

Böttcher MC, Bette M, et al. A basal- cell-like compartment in head and neck squamous cell carcinomas represents the invasive front of the tumor and is ex- pressing MMP-9. Oral Oncol. 2010 Feb; 46(2):116–22.

• 27. Suzuki H, Masuda N, Shimura T,

Araki K, Kobayashi T, Tsutsumi S, et al. Nuclear beta-catenin expression at the in- vasive front and in the vessels predicts liver metastasis in colorectal carcinoma. Anticancer Res. 2008 May-Jun;28(3B): 1821–30.

• 28. Tumuluri V, Thomas GA, Fraser IS.

Analysis of the Ki-67 antigen at the inva- sive tumour front of human oral squa- mous cell carcinoma. J Oral Pathol Med. 2002 Nov;31(10):598–604.

• 11. Jerjes W, Upile T, Radhi H, Petrie A,

Adams A, Callear J, et al. Delay in patho- logical tissue processing time vs. mortal- ity in oral cancer: short communication. Head Neck Oncol. 2012 Apr;4:14.

• 12. Upile T, Jerjes W, Kafas P, Harini S,

Singh SU, Guyer M, et al. Salivary VEGF: a non-invasive angiogenic and lymphangio- genic proxy in head and neck cancer

• prognostication. Int Arch Med. 2009 Apr;

2(1):12.

• 13. Upile T, Jerjes W, Mahil J, Sudhoff H,

Hopper C, Wright A. Blood product trans- fusion and cancer prognosis. Clin Adv Hematol Oncol. 2009 Oct;7(10):656–61.

• 14. Upile T, Jerjes W, Mahil J, Upile N,

Sudhoff H, Wright A, et al. An explanation for the worsened prognosis in some can- cer patients of perioperative transfusion: the time-dependent release of biologically active growth factors from stored blood

• products. Eur Arch Otorhinolaryngol.

2011 Dec;268(12):1789–94. 15. Upile T, Jerjes W, Radhi H, Al-Khawalde M, Kafas P, Nouraei S, et al. Vascular mimicry in cultured head and neck tumour cell lines. Head Neck Oncol. 2011 Dec;3(1):55.

• 16. Upile T, Jerjes W, Sandison A, Singh S,

Rhys-Evans P, Sudhoff H, et al. The direct effects of stored blood products may worsen prognosis of cancer patients; shall we transfuse or not? An explanation

• f the adverse oncological consequences
• f blood product transfusion with a test-

able hypothesis driven experimental re- search protocol. Med Hypotheses. 2008 Oct;71(4):489–92.

• 17. Nanashima A, Sumida Y, Abo T,

Nagasaki T, Tobinaga S, Fukuoka H, et al. Comparison of survival between ana- tomic and non-anatomic liver resection in patients with hepatocellular carcinoma: significance of surgical margin in non- anatomic resection. Acta Chir Belg. 2008 Sep-Oct;108(5):532–7.

• 18. Tralhão JG, Kayal S, Dagher I, Sanhueza

M, Vons C, Franco D. Resection of hepato- cellular carcinoma: the effect of surgical margin and blood transfusion on long- term survival. Analysis of 209 consecu- tive patients. Hepatogastroenterology. 2007 Jun;54(76):1200–6. 19. Upile T, Jerjes W, Singh S, Al-Khawalde M, Hamdoon Z, Radhi H, et al. The use of specific anti-growth fac- tor antibodies to abrogate the oncological

References

• 1. Jerjes W, Upile T, Petrie A, Riskalla A,

Hamdoon Z, Vourvachis M, et al. Clinico- pathological parameters, recurrence, locoregional and distant metastasis in 115 T1–T2 oral squamous cell carcinoma

• patients. Head Neck Oncol. 2010 Apr;2:9.
• 2. Upile T, Fisher C, Jerjes W, El Maaytah M,

Searle A, Archer D, et al. The uncertainty

• f the surgical margin in the treatment of

head and neck cancer. Oral Oncol. 2007 Apr;43(4):321–6.

• 3. Upile T, Fisher C, Jerjes W, El

Maaytah M, Singh S, Sudhoff H, et al. Recent technological developments: in situ histopathological interrogation of surgical tissues and resection margins. Head Face Med. 2007 Mar;3(1):13.

• 4. Nason RW, Binahmed A, Pathak KA,

Abdoh AA, Sándor GK. What is the ade- quate margin of surgical resection in oral cancer? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 May;107(5): 625–9.

• 5. Upile T, Jerjes W, Betz CS, El Maaytah M,

Wright A, Hopper C. Optical diagnostic techniques in the head and neck. Dent

• Update. 2007 Sep;34(7):410–2, 415–6,

419–20 passim.

• 6. Upile T, Jerjes W, Nouraei SA, Singh S,

Clarke P, Rhys-Evans P, et al. How we do it: a method of neck dissection for histo- pathological analysis. BMC Surg. 2007 Oct; 7:21.

• 7. Jerjes W, Upile T, Alexander Mosse C,

Hamdoon Z, Morcos M, Morley S, et al. Prospective evaluation of 110 patients following ultrasound-guided photody- namic therapy for deep seated patholo-

• gies. Photodiagnosis Photodyn Ther.

2011 Dec;8(4):297–306.

• 8. Jerjes W, Upile T, Hamdoon Z,

Alexander Mosse C, Morcos M, Hopper C. Photodynamic therapy outcome for T1/ T2 N0 oral squamous cell carcinoma. Lasers Surg Med. 2011 Aug;43(6):463–9.

• 9. Jerjes W, Upile T, Hamdoon Z,

Al-Khawalde M, Morcos M, Mosse CA, et al. CO2 laser of oral dysplasia: clinico- pathological features of recurrence and malignant transformation. Lasers Med Sci. 2012 Jan;27(1):169–79.

• 10. Jerjes W, Upile T, Radhi H, Petrie A,

Abiola J, Adams A, et al. cTNM vs. pTNM: the effect of not applying ultrasonogra- phy in the identification of cervical nodal

• disease. Head Neck Oncol. 2012 Mar;4:5.