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Revista Española de Cirugía Oral y Maxilofacial

On-line version ISSN 2173-9161Print version ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.28 n.3 Madrid May./Jun. 2006




Estadios precoces de cáncer oral: pronóstico en relación con gradación histológica, linfangiogenesis intratumoral y expresión de factor de crecimiento endotelial vascular tipo-C (VEGF-C)



Dear director:

I have read with great interest the discussion of our article "Early stage oral cancer: prognosis with regard to histological grading, intratumoral lymphangiogenesis, and the expression of vascular endothelial growth factor- C (VEGF-C)" Rev Esp Cir Oral y Maxilofac 2006;28(1):25- 40. For our investigation group receiving the attention of one of the most prestigious head and neck surgeons of the world, such as Prof. Jatin P. Shah, is indeed an honor. Moreover, we consider his being recent appointment as President of the International Academy of Oral Oncology (IAOO) an excellent choice. However, we believe that some of the appraisals made in the discussion do not reflect the purpose of our work:

1. Prof. Shah indicates that "given that the study at hand wishes to evaluate LI+ as a predictor of pN+, the cohort is inadequate". In the introduction to the study we indicate that the aim of the study was to look for a correlation between LI and prognosis. The object was to relate lymphangiogenesis with the presence of recurrence at a local or cervical level, as well as with survival. If we use a group of patients with tumors < 4 cm, and if no neck involvement has been verified anatomically and pathologically, what sense would there be in evaluating the findings with the presence of neck involvement (pN+)?

2. In another paragraph he indicates that "the authors failed to demonstrate overall clinical utility of the grading schemes". We find this result quite logical, in fact, this was our initial hypothesis. We do not find the different histological grading systems particularly useful from a clinical point of view. Studies such as those carried out by Dantas & cols.,1 as well as Crissman & cols.,2 support this hypothesis.

3. This North American author indicates that selecting patients undergoing elective neck dissection would have been more appropriate. Now then, as is clearly reflected in the section Material and Methods of our work, all patients in the study were subjected to elective neck dissection. Shah later indicates that "the absence of nodal metastases in this population is somewhat unusual". The absence of nodal involvement is quite logical as from the moment that we are dealing with a factor that must be included in the cohort of the study. We precisely wanted to chose T1-T2 pN0 cases because they are the most susceptible to curative therapy, and because finding new prognostic factors would be more transcendent.

4. In the discussion Shah indicates that the question that we should be trying to answer is if these new channels are interconnected and if they anastomose with native lymphatic networks. In our opinion, this question is of no particular transcendence. What we should really be questioning is if there is invasion by neoplastic cells through the primitive lymphatic system, or if this is achieved by new channels that are interconnected as has been reflected in previous publications.3 In this respect, Shah correctly points out in the last paragraph of his comments, the transcendental importance of finding tumor emboli. Our group has shown in previous works the occasional presence of cellularity in the interior of new lymphatic vessels (Fig. 1) but we have not been able to significantly relate these findings statistically with an unfavorable outcome in these cases. In fact, neither have we been able to demonstrate in a reliable manner if these are actually neoplastic cells or if they are other components of the immune system.

I hope these points have served to clarity the purpose of our study.

Yours faithfully.

Mario F. Muñoz Guerra
Servicio de Cirugía Oral y Maxilofacial
Hospital Universitario de la Princesa, Madrid, España




1. Dantas DD, Ramos CC, Costa AL, Souza LB, Pinto LP. Clinical-pathological parameters in squamous cell carcinoma of the tongue. Braz Dent J 2003;14:22-5.

2. Crissman JD, Liu WY, Gluckman JL, Cummings G. Prognostic value of histopathologic parameters in squamous cell carcinoma of the oropharynx. Cancer 1984;54:2995-3001.

3. Kyzas PA, Geleff S, Batistatou A, Agnantis NJ, Stefanou D. Evidence for lymphangiogenesis and its prognostic implications in head and neck squamous cell carcinoma. J Pathol 2005;206:170-7.



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