Discuss the

clinical
significance of
intra- and inter-
tumour
heterogeneity in
oral squamous cell
carcinoma.

Provider: Dr Jeffrey O’Sullivan

Supervisor: Dr Brett Duane
 “
CONTENTS

1. ORAL SQUAMOUS CELL

CARCINOMA
2. TUMOUR HETEROGENEITY
3. TUMOR HETEROGENEITY IN
OSCC
4. CLINICAL SIGNIFICANCE AND
APPLICATIONS
5. CONCLUSIONS
2
ORAL SQUMOUS CELL
CARCINOMA 90% of Head and Neck

RISK
Cancers are OSCC “
PROGNOS TREATME
FACTORS IS NT
• Tobacco smoking and chewing • Surgery
• TNM STAGING
• Alcohol consumption • radiotherapy
• TUMOUR
• Betel quid use • chemotherapy
GRADING
• HPV STATUS • targeted therapy
- 16 & 18
- 25% mouth cancers  base of
tongue
- 35% throat cancers 
DIAGNOSI SURVIVAL
oropharyngeal
S RATES
• Incisional • 50% overall survival rate
biopsy • No marketed improvement in survival in last 20 years
• Fine needle 3
TUMOUR
HETEROGE
NETY

1. INTRATUMOUR HETEROGENEITY Within the same

tumor
2. INTERTUMOUR HETEROGENEITY Between tumour
of the same type
OBSERVED AT 3 LEVELS
 Genetic
 Epigenetic
 Phenotypic

4
CLONAL
EVOLUTION
• Tumour cells arise from a single mutated cell
MODEL
• Mutations accumulated over time

• Subpopulations of subclones
 evolutionary advantage
 become dominant over time by being
naturally selected

• Cells more aggressive, invasive and resistant

to therapy

5
 CANCER STEM CLONAL
CELL MODEL EVOLUTION MODEL
• subset of cells have ability to form
tumours

• cancer stem cells

• self renewal and differentiation

• drive tumour initiation and progression

• produce a population of distinct cell

types
6
INTEGRATING BOTH MODELS

7
 Tissue
FACTORS FOR
composition
INTERTUMOR • Set of mucosal and submucosal tissue compositions
• Interactions of tumour cells with microenvironment  malignancy
HETEROGENETY
• Tumour cells experience range of microenvironment signals
Clinical significance
IN OSCC • Cancers at different sites may be considered different biological subentities
• Difference in prognosis and disease related outcomes
• Studies to examine microenvironment

8
FACTORS Diversified Microbial flora
FOR • Microbial flora considered risk factor in OSCC
INTRATU • Bacteria  H. pylori
 Streptococcus anginosus
MOR
• Viruses  HPV 16/18
HETEROG • Fungi  Candida
ENETY Clinical significance
• Different prognosis
IN OSCC • Different treatments

9
FACTORS Carcinogenic attack
FOR •
•
OSCC unique due to risk factors: smoking, alcohol
Different conbinations
BOTH • May have synergistic effect

INTERTU
OPMD
MOUR &
•
INTRATU •
may be preceeded by OPMDs
Each have unique microenvironment
• Carried forward during malignancy
MOUR • Potential to modulate tumour phenotype and
behavior
HETEROG • Submucose fibrosis associated OSCC

ENEITY
IN OSCC 10
FACTORS Pro-tumorinogenic cytokines
FOR •
•
TNF alpha & IL6
Elevated by age/inflammation/OPMDs/ microenvironment
BOTH
INTERTU Epithelial turnover rate
MOUR &
•
INTRATU •
Time required to replace all cells in epithelium
Site specific in oral cavity
• factors overexpressed in malignancy :
MOUR •
EGF,KGF,IL1,TGF alpha and beta
May be why cancers have faster growth
HETEROG
ENEITY
IN OSCC 11
 MEASURING
HETEROGENEITY “
Measurement  clinically significant & applicable
• Preidentifed markers
• Extensive tumour dissection Difficult to translate from clinical research to
• Isolating and analyzing individual the clinic
nuclei
• Ultra deep sequencing of mutations

Next generation sequencing  used to measure genetic heterogeneity

12
 QUANTIFYING TUMOUR
HETEROGENEITY “
• Genomically distinct
subpopulations of cells in tumour

• Differences among mutated loci

(fraction of sequence reads
show mutant allele)

• Distribution of mutant allele

fractions among loci

• MATH (consequence of multiple

cell populations in a tumour)

• MAF larger in heterogeneous cells

• MATH higher in heterogeneous cells
13
Studies
1st STUDY
looking at
▪ 74 HNSCC cases from Strkansky et al study
genetic ▪ MATH not related to mutation rate
heterogeneity ▪ Relationship of MATH with 3 prognostic variables for
in oral cancer SCC
- Disruptive TP53 mutations  only disruptive TP53
related to higher MATH
- HPV status  + status related to lower MATH
- Cigarette smoking  MATH associated with pack year
history

Highest heterogeneity assessed by MATH  worse clinical variable

14
Studies
2nd STUDY
looking at
▪ Same data analyzed
genetic ▪ Tumor MATH related to individual clinical outcomes
heterogeneity ▪ Increasing MATH related to shorter overall survival
in oral cancer ▪ individual variable
▪  when prognostic variables taken into account

HIGH genetic Heterogeneity risk factor for worse outcomes in HNSCC

• Limited number of patients

• Same institution
• No controlled treatment study design

15
Studies
2nd STUDY
looking at
▪ Same data analyzed
genetic ▪ Tumor MATH related to individual clinical outcomes
heterogeneity ▪ Increasing MATH related to shorter overall survival
in oral cancer ▪ individual variable
▪  when prognostic variables taken into account

HIGH genetic Heterogeneity risk factor for worse outcomes in HNSCC

• Limited number of patients

• Same institution
• No controlled treatment study design

16
And even
more
numbers DIAGNOSIS

PROGNOSIS
TREATMENT

17
DIAGNOSIS

18
PROGNOSIS

19
TREATMENT

20
 “
CONCLUSION

21
22
23
24