Journal of Cancer Research and Therapeutics

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 18  |  Issue : 1  |  Page : 33--41

Significance of HIF-1α and CD105 in establishing oral squamous cell carcinoma associated with oral submucous fibrosis a distinct clinicopathological entity


Alka Harish Hande1, Minal S Chaudhary1, Amol R Gadbail2, Madhuri N Gawande1, Swati K Patil1, Prajakta R Zade1, Preethi N Sharma1, Shradha G Jaiswal3, Archana M Sonone1,  
1 Department of Oral Pathology and Microbiology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
2 Department of Dental Surgery, Indira Gandhi Government Medical College, Nagpur, Maharashtra, India
3 Department of Oral Pathology and Microbiology, Sir Aurobindo College of Dentistry, Indore, Madhya Pradesh, India

Correspondence Address:
Alka Harish Hande
Department of Oral Pathology and Microbiology, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences (Deemed to be University) Sawangi (Meghe), Wardha - 442 001, Maharashtra
India

Abstract

Context: Oral squamous cell carcinoma associated with oral submucous fibrosis (OSCC with OSMF) is clinicopathologically a distinct entity. However, scientific proof in view of assessment of biomarkers of hypoxia and neoangiogenesis to differentiate them are lacking. The expression of hypoxia-inducible factor 1-α (HIF-1α) and CD105 in OSCC with and without OSMF possibly will be explicated along these lines. Aim: This study aims to evaluate the molecular basis of hypoxia and neoangiogenesis in terms of immunohistochemical expression of HIF-1α and CD105 in OSCC with and without OSMF cases. Settings and Design: A retrospective cohort. Subjects and Methods: The study comprise of 203 histopathologically diagnosed surgically operated cases of OSCC retrieved from the departmental archives. The OSCC cases were subgrouped into two, OSCC with OSMF (Group I) and OSCC without OSMF (Group II). The evaluation of hypoxia and angiogenesis was carried out by immunohistochemical markers, HIF-1α and CD105. MVD is the parameter of angiogenesis expressed by CD105. Statistical Analysis Used: Differences in CD105, and HIF-1α immunoreactivity between study groups were done using descriptive statistics using “Kruskal–Wallis test,” “Mann-Whitney test.” Statistical significance was set at P < 0.05. Results: On comparison of MVD in Group I and II, statistically significant difference was found in MVD (8.88 ± 3.41, 16.13 ± 5.86, P = 0.0001). The HIF1-α expression was less in Group I (6.85 ± 2.62) as compare to Group II (7.22 ± 3.08) but the difference was statistically nonsignificant (P = 0.35). Conclusions: The OSCC with OSMF is not only clinicopathologically distinct entity of OSCC but also diverse in its molecular pathogenesis as explicited by distinct expression of HIF-1 α and CD105.



How to cite this article:
Hande AH, Chaudhary MS, Gadbail AR, Gawande MN, Patil SK, Zade PR, Sharma PN, Jaiswal SG, Sonone AM. Significance of HIF-1α and CD105 in establishing oral squamous cell carcinoma associated with oral submucous fibrosis a distinct clinicopathological entity.J Can Res Ther 2022;18:33-41


How to cite this URL:
Hande AH, Chaudhary MS, Gadbail AR, Gawande MN, Patil SK, Zade PR, Sharma PN, Jaiswal SG, Sonone AM. Significance of HIF-1α and CD105 in establishing oral squamous cell carcinoma associated with oral submucous fibrosis a distinct clinicopathological entity. J Can Res Ther [serial online] 2022 [cited 2022 Jul 3 ];18:33-41
Available from: https://www.cancerjournal.net/text.asp?2022/18/1/33/341163


Full Text



 Introduction



Approximately 263,000 new cases of oral squamous cell carcinoma (OSCC) are reported globally per annum.[1] OSCC shows a high susceptibility for invasive growth and cervical lymph node metastasis.[1] Commonly OSCC is preceded by clinically identifiable diseases that are oral potentially malignant diseases. Among these are oral lichen planus, erythroplakia, leukoplakia, and oral submucous fibrosis (OSMF). These lesions are observed in alliance with and preceding OSCC. They are inconsistent in their malignant impending as well as their inherited environment.[2]

OSMF, now worldwide acknowledged as the disease of Southeast Asia and Indian subcontinent due to the widespread practice of areca nut chewing and its commercial preparation. The malignant potential of OSMF was first described by Paymaster in 1956 on observation that one third of the patients of OSCC had associated with OSMF.[3] The malignant transformation rate has been reported to 7%–12% cases of OSMF.[4],[5] The characteristic feature of OSMF, particularly fibrosis proposes a likelihood of hypoxic milieu in diseased tissues.[6],[7] This metabolic change in the form of fibrosis shown to cause the upregulation of proteins such as hypoxia-inducible factor 1-α (HIF-1α). It stimulates transcriptive induction of a series of genes involved in iron and glucose metabolism, cell proliferation, and its survival.[8] Furthermore, it plays a key role in increase in tumor angiogenesis, which is demonstrated by its overexpression in most of the human cancers including breast, cervix, lung, and oral cavity.[8] The key universal characteristic of solid tumors, that is, neovascularization and augmented glycolysis, represents the adaptations to a hypoxic microenvironment that are correlated with tumor invasion and metastasis, which results in poor prognosis. Thus, HIF-1α is an integral part of tumor progression in OSCC.[8]

The presence of copper in areca nut seems to activate HIF-1α. Apart from this development of reactive oxygen species (ROS) might be additional inducing factor for HIF-1α. The formation of ROS through practice of areca quid chewing may be one of the etiological factors of OSCC. It is consequently realistic to recommend that elevated quantity of copper formed and ROS produced possibly accountable to some extent for the upregulation of HIF-1α in OSCCs concomitant with practice of areca quid chewing.[8]

CD105 (endoglin) is a transmembrane phosphorylated glycoprotein, a fundamental constituent of the transforming growth factor beta receptor signaling pathway. This pleiotropic cytokine moderates angiogenesis by the regulation of diverse cellular roles, together with proliferation, differentiation, and migration. CD105 is fundamental for neoangiogenesis and vascular growth.[9]

Very few studies are there representing OSCC with OSMF clinicopathologically a distinct entity. The discrete mechanism of areca nut carcinogenesis is mainly thought to be responsible for these differences. It is documented that the majority of these patients are younger males with improved prognostic factors such as better grade of tumor differentiation, a less significant incidence of nodal metastases and extra capsular spread.[10],[11] However, scientific proof in view of assessment of biomarkers of hypoxia and neoangiogenesis to differentiate them are lacking. The instigation of HIF-1α and CD105 in OSCCs concomitant with practice of areca quid chewing possibly will be explicated along these lines.

Aim

This study aims to evaluate the molecular basis of hypoxia and neoangiogenesis in terms of immunohistochemical expression of HIF-1α and CD105 in extracellular matrix of OSCC with and without OSMF cases.

 Subjects and Methods



The present study was carried out at the “Department of Oral Pathology and Microbiology”, after receiving approval from Institutional Ethical Committee (DMIMS (DU)/IEC/2015-16/1575).

The written informed consent was acquired from the patients regarding use of their data and archival tissue samples. Further 203 histopathologically diagnosed surgically operated cases of OSCC retrieved from the departmental archives. On the basis of association of OSMF the OSCC cases were sub grouped into two, OSCC with OSMF (Group I, 102 cases) and OSCC without OSMF (Group II, 101 cases). Demographic data pertaining to clinical and histopathological parameters were noted. The paraffin embedded tissue sections of 4 μm were obtained from archival tissues of OSCC and OSCC with OSMF, which were stained for routine hematoxylin and eosin and for the expression of HIF-1a and CD105 by immunohistochemistry (IHC).

Immunohistochemical staining

For IHC, Universal Immunoenzyme polymer method was employed. The tissue sections were deparaffinized with xylene and hydrated. Antigen retrieval for HIF-1α was performed by subjecting tissue sections to 0.01 M sodium citrate buffer (pH 6.0) and to Proteinase K for CD105. Endogenous peroxidase activity was blocked by incubating the section with 3% H2O2 in methanol for 30 min. To prevent nonspecific reactions, sections were incubated with 10% serum for 10 min. HIF-1α (Diluted 1:100, polyclonal Rabbit HIF-1α, Product code: NB 100-479, Novus Biologicals) and CD-105(Diluted 1:30, Monoclonal Mouse Anti-Human CD105, Endoglin, Clone SN6 h; Product code: M3527, Dako, North America Inc.) were incubated at room temperature in a humidifying chamber for 60 min. Tissue section of pyogenic granuloma was used as a positive control for CD105 and skin for HIF-1α. One section from each positive control was used as the negative control by omitting the primary antibody and by incubating with serum. After the primary antibody and antigen reaction, the sections were rinsed in phosphate buffered saline (PBS) three times for 10 min each. The horseradish peroxidase (HRP) labeled Polymer Antimouse (DakoEnVision System HRP Labelled Polymer Anti mouse, Product Code: K4000, Dako North America Inc.) was incubated at room temperature in humidifying chamber for 30 min. After the PBS washing three times for 10 min each, freshly prepared substrate/chromogen solution of 3, 3' diaminobenzidine (DAB) in provided buffer (mixing 5 μl of concentrated DAB in 50 ml of substrate buffer) was used to visualize the antigen-antibody reaction. Finally, the sections were counterstained in Mayer's hematoxylin.

Assessment of immunohistochemically stained sections

Two oral pathologists evaluated immunohistochemically stained tissue sections independently in double-blinded manner. Differences in interpretation were resolved by consensus review with a third oral pathologist. Sections stained with HIF-1α and CD-105 antibody were examined under Leica DM LB2 (Leica microscope) at ×100 magnification.

Morphometric analysis of tumor vessels (CD105 immunopositive cells)

Quantitative analysis of the microvessel density (MVD) was performed using a computer-aided image analysis system Leica QWin Pro V 3.5.0 at ×100 magnification. To determine the MVD, slides were screened and three areas with highest number of stained microvessels (hotspots) were selected. Based on the criteria of Weidner et al.,[12] a highlighted endothelial cell or a cell cluster clearly separated from adjacent microvessels and other connective tissue elements was regarded as a distinct countable microvessel. A lumen was not required, nor was the presence of red blood cells. Single cell sprouts were included in the counts [Figure 1].{Figure 1}

Assessment of hypoxia-inducible factor 1-α positive cells

The immunoreactivity of HIF-1α was examined under light microscope (Leica) at ×100 magnification. The rating of proportion of immunopositive cells was made as follows: (1) if 1%–10% immunopositive cells; (2) if 11%–50%; (3) when, 51%–80%; and (4) if more than, 80% immunopositive cells are present in the section. The scoring of staining intensity was made as follows. If weak staining score 1 was considered,for moderate staining score 2 and for intensive staining score 3 was given. The absolute immunoreactive score was determined by multiplication of the score of percentage of number of immunopositive cells and intensity of immunoexpression.[13]

Statistical interpretation

The mean score was obtained for MVD and HIF-1α expression in all the groups. The acquired information was interpreted statistically by means of SPSS version 17 for windows, SPSS Inc., Chicago, IL. The obtained scores were compared in Group I and II using one way ANOVA and Multiple comparisons by using Tukey HSD test. The obtained scores were also compared and correlated with different parameters of OSCC (TNM stage, lymph node metastasis, and histopathological grades). Differences in CD105, and HIF-1α immunoreactivity between and within study groups were done by using descriptive statistics using “Kruskal–Wallis test”, “Mann–Whitney test”, and “unpaired t test.” Statistical significance was set at P < 0.05.

 Results



The present study comprises of 203 cases of OSCC, among which 102 were suffering from OSCC with OSMF (Group I) and 101 were suffering from OSCC without OSMF (Group II) On evaluation of age range, Group I cases were younger (46.99 ± 12.90 years) compared with Group II cases (52.54 ± 10.73 years) (P = 0.000). In general, OSCC was observed mostly in males (75.86%) as compared to females (24.13%) “(Male: female ratio = 3.14:1).” Clinical “TNM staging” for Group I and Group II cases that is Stage I, II, II and IV were broadly classified into two stages. “Early stage” comprises of Stage I and Stage II where as “advanced stage” of Stage III and Stage IV. We observed statistically significant variation in clinical “TNM staging” between Group I and Group II cases (P = 0.001). 48% cases of Group I were presented with “early stage” as compared to 17.82% cases of Group II. In contrast to this 82.17% cases of Group II were presented in “advanced stage” as compared to 52% cases of Group I. On evaluation of difference in histopathological grading of OSCC, statistically significant difference was observed amongst well differentiated squamous cell carcinoma (WDOSCC), moderately differentiated squamous cell carcinoma (MDOSCC), and poorly differentiated squamous cell carcinoma (PDOSCC) between Group I and II (P = 0.0001). Further 62.7% cases of Group I were in WDOSCC grade in contrast to 32.7% cases of Group II. Moreover, 57.4% of Group II were in MDOSCC grade in contrast to 30.4% cases of Group I. Similarly, in PDOSCC grade more cases (9.9%) were from Group II as compare to Group I (6.9%). On evaluation of difference in regional lymph node metastasis, 47.5% cases of Group II showed metastasis to cervical group of lymph nodes in contrast to 31.4% cases of Group I (P = 0.018). On evaluation of 5-year disease-free survival rate, it was observed significantly higher in Group I (57.89%) in contrast to Group II cases (42.16%), (P = 0.0004) [Table 1].{Table 1}

Comparison of biomarkers CD105 (MVD) HIF-1-α expression with clinicopathological features of Group I and II

The evaluation of hypoxia and angiogenesis was carried out by immunohistochemical markers, HIF-1α and CD105. MVD is the parameter of angiogenesis expressed by CD105.

On comparison of MVD in Group I and II, statistically significant difference was found in MVD (8.88 ± 3.41, 16.13 ± 5.86, P = 0.0001,). The HIF1-α expression was less in Group I (6.85 ± 2.62) as compare to Group II (7.22 ± 3.08) but the difference was statistically nonsignificant (P = 0.35) [Table 2].{Table 2}

There were 64 cases in WDOSCC grade of Group I whereas 33 were in Group II. On comparison between MVD in Group I and Group II cases, statistically significant difference was found in MVD (8.30 ± 3.01, 14.65 ± 5.40, P = 0.0001). The expression of HIF1-α was found more in Group I (6.79 ± 2.64) as compared to Group II (6.24 ± 3.46) but the difference was statistically nonsignificant (P = 0.38). There were 31 cases in MDOSCC grade of Group I whereas 58 were in Group II. On comparison between MVD in Group I and II cases, statistically significant difference was observed in MVD (9.81 ± 4.24, 16.58 ± 5.93, P = 0.0001). HIF1-α expression was found less in Group I (6.83 ± 2.78) as compared to Group II (7.65 ± 3.00) but the difference was statistically nonsignificant (P = 0. 21). There were 7 cases in PDOSCC cases of Group I whereas 10 were in Group II. On comparison between MVD in Group I and Group II cases, statistically significant difference was found in MVD (10.09 ± 1.13, 18.39 ± 6.27, P = 0.0001). HIF1-α expression was found less in Group I (7.42 ± 1.81) as compared to Group II (8 ± 0.66) but the difference was statistically nonsignificant (P = 0.37) [Table 3].{Table 3}

There were 49 cases in Group I whereas 18 cases in Group II in early clinical TNM stage. On comparison of MVD amongst Group I and Group II, statistically significant difference was found in MVD (8.18 ± 3.32, 15.05 ± 6.50, P = 0.0001, S). The expression of HIF1-α was found more in Group I (6.69 ± 2.70) as compared to Group II (6.66 ± 3.92) but the difference was statistically nonsignificant.

There were 53 cases in Group I whereas 83 were in Group II in advanced clinical TNM stage. On comparison of MVD in Group I and II, statistically significant difference was found in MVD (9.53 ± 3.40, 16.36 ± 5.72, P = 0.0001, S). The expression of HIF1-α was found more in Group II (7.34 ± 2.88) as compared to Group I (7.00 ± 2.55); however, the difference was statistically nonsignificant [Table 4].{Table 4}

Forty-eight cases of Group II show metastasis, as compare to 32 cases of Group I. On comparison of MVD in metastatic cases amongst Group I and II, statistically significant difference was found in MVD (9.11 ± 2.77, 17.89 ± 5.73, P = 0.0001). The difference in expression of HIF1-α was found statistically significant (6.43 ± 2.85, 7.85 ± 2.75, P = 0.029) in Group I and II cases.

Seventy cases of Group I were negative for metastasis, as compare to 53 cases of Group II. On comparison of MVD in nonmetastatic cases amongst Group I and II cases, statistically significant difference was found in MVD (8.78 ± 3.68,14.53 ± 5.55, P = 0.0001). The expression of HIF1-α was found more in nonmetastatic cases of Group I (7.04 ± 2.51) as compared to Group II (6.66 ± 3.28) however the difference was statistically nonsignificant [Table 5].{Table 5}

 Discussion



In India, the incidence of OSMF has increased over the 0.03% to 6.42% in four decades.[14] Statistics available earlier report approximately of 5 million OSMF patients in India.[15] Evidently, existing preventive and management strategies for OSMF are insufficient.[16] A study specified that approximately “10% of these may transform into malignancy.”[17] In Indian subcontinent and Southeast Asia, OSCC with OSMF is one of the most prevalent malignancies.[18] Recently, 25.77% of OSCC cases have been associated with OSMF is reported.[19] Therefore, latest trend indicates that this should be considered as a separate distinct entity. These distinctions are thought to develop from distinct pathogenesis of areca nut carcinogenesis. The atrophic epithelium in OSMF is results from rapid turnover rate of epithelial cells. In context to this a proposed premise states that in the course of malignant progression of OSMF, the altered mucosal cells might preserve the genomic reminiscence of more rapid differentiation and maturation which sub sequentially results in better grade of tumor differentiation.[20] This proposition finds support in the observations by various studies like the prevalence in younger age males with better grade of tumor differentiation and less incidence of lymph node spread.[10],[11] In view of these overhead evidences we intended to associate the clinicopathological characteristics of Group I and II with expression of CD-105 and HIF1-α.

Neoangiogenesis (CD105) in Group I and II

The result of the present study showed significantly increased MVD in Group II [Figure 2] as compared to Group I cases [Figure 3]. Further on the comparison of MVD in WDOSCC grade of Group I and II cases, MVD was increased significantly in Group II as compared to Group I. In MDOSCC and PDOSCC grades of Group I and II cases, MVD was considerably increased in Group II as compare to Group I cases. The increased expression of CD105 as evidenced by MVD was observed from WDOSCC to MDOSCC to PDOSCC. The study results are in conformity with Kumagai et al.[21] and Khalili et al.[22] CD-105 is a realistic molecular biomarker in the assessment of the development of OSCC. This could be attributed to the fact that new vessel formation is an essential condition for tumor growth and progression, as neoplastic lesions with a more abundant microvascular background show a growth advantage compared to tumors with a less developed microvascular network.[23] Intratumoral newly formed vessels give the tumor the ability to metastasize, representing a key factor in defining the overall aggressiveness and the prognosis of the tumor itself. However, our results are not in agreement with Tae et al.[24] and Carlile et al.[25]{Figure 2}{Figure 3}

On the assessment of MVD, among TNM stages in Group I and II cases, we observed gradually increased MVD from TNM Stage I to Stage IV in Group I and II cases. Further significantly increased MVD was observed in Group II as compared to Group I cases in each TNM stage. These results are in agreement with Martone et al.,[26] Kyzas et al.,[27] Nair et al.[28] Significantly higher CD105+ MVD values in advanced stage tumors was correlated with the more aggressive tumor phenotype as well as with an advanced clinicopathological stage and the incidence of lymph node metastasis in HNSCC. However, Porpino Mafra et al. recommended that vascular alteration is implicated in oral carcinogenesis, though there was no confirmation of a considerable relationship with clinicopathological stages of the OSCC.[29]

Considering the differences in clinicopathological parameters in Group I and II cases, we assessed the correlation of MVD with the status of lymph node metastasis. We observed significantly increased MVD in metastatic cases of Group II as compared to Group I cases. These observations could correlate with 31.4% of Group I cases demonstrated metastasis to cervical lymph nodes as compared to 47.5% of Group II cases. These results are in conformity with Martone et al.,[26] and Kyzas et al.[27] In tumor, the microvessels are structurally and functionally complex and diverse. Their architecture may show a chaotic pattern, mostly of different sizes, aberrant morphology, tortuous, without clear lumen and irregularly branched.[30] Thus, the assessment of neoangiogenesis using CD105 can be an important prognostic marker which may help in distinguishing between OSCC with (Group I) and without OSMF cases (Group II).

Hypoxia-inducible factor 1-α in Group I and II

The result of the present study showed increased HIF-1α expression in Group I (7.22 ± 3.08) [Figure 4] as compared to Group II (6.85 ± 2.62) [Figure 5], but the difference was statistically nonsignificant (P = 0.35).{Figure 4}{Figure 5}

The role of HIF-1α in human tumor progression is evidenced by the scientific clinical statistics studied in benign tumors of skin, prostate, breast, lung, colon, pancreas, brain, duodenum, ovary and kidney as well as primary malignant cancers and metastatic tumors.[31] Our observations are in accordance with Lin et al.,[32] Eckert et al.,[13] and Chang.[33] The HIF-1α expression as observed in both the groups of OSCC be considered as an initial incident in progression of OSCC.

Thus, we hypothesize that in the initial stage of OSCC with OSMF there is pre-existing fibrosis which is indicative of increased HIF-1α expression. In Group I, due to epithelial mesenchymal transition (EMT) the connective tissue in preexisting OSMF probably alters the fibrotic nature and so hypoxia is due to epithelial proliferation in tumor which is same in both the groups. However, in contrast to this, overexpression of HIF-1α is considered as an indicator of favorable prognosis in OSCC.[34],[35] Probable intention for these contradictory effects may possibly be explained as the HIF-1α protein overexpression is not only related to poor oxygenation of tissue that is hypoxia. On the other hand, it is owing to alterations and adaptations in oncogenes or tumor suppressor genes.

Further on comparison of HIF-1α in WDOSCC grade, statistically nonsignificant difference in the expression of HIF1-α was found in Group I (6.79 ± 2.64) and II cases (6.24 ± 3.46). In the initial stage of OSCC more hypoxia due to extensive fibrosis may effects in more HIF1-α expression in Group I cases. As the disease (grade) progresses, the mechanism of degradation of ECM sets in, which results in stabilization and so no difference in HIF1-α in further grades of OSCC. During transformation of OSMF into malignancy the integral presence of fibrosis may not play a role in additional hypoxia or differential mechanism of degradation of ECM sets in, so no further difference remains once malignant transformation in OSMF takes place. However, a reduced amount of appearance of HIF-1α in Group I and further less angiogenesis may relate with its better grade.

In MDOSCC and PDOSCC grades of Group I and II cases, HIF-1α was considerably increased in Group I as compare to Group II. The positive correlation of the HIF-1α expression with increasing grades of OSCC could be attributed to mutation which may cause the production of a dysfunctional von Hippel–Lindau tumor suppressor protein which results in an inhibition of degradation of HIF-1α and hence a prolonged HIF-1α half-life.[36] Furthermore, the activation of the PI3K, Akt, and mTOR pathways which play a key role in carcinogenesis are believed to promote stabilization of HIF-1α.[37]

On the assessment of HIF-1α among TNM stages in Group I and II cases, we observed gradually increased HIF-1α from TNM Stage I to Stage IV in Group I and II cases. Further on evaluation of HIF-1α in each TNM stage of Group I and II cases, statistically nonsignificant difference was observed. Lin et al. observed a positive correlation of HIF-1α overexpression with advanced tumor and lymph node status in OSCCs. As the advanced tumor and lymph node status at all times consequence in a further progressive clinicopathological stage of OSCC, it is easy to explicate why OSCCs with the advanced overexpression of HIF-1 α are predisposed to have the further progressive clinicopathological stages.[37]

Considering the differences in clinicopathological parameters in Group I and II cases, we assessed the correlation of hypoxia (HIF-1α) with status of lymph node metastasis. We observed increased HIF-1α expression in metastatic cases of Group II in contrast to Group I. But the difference was statistically nonsignificant. These observations could be correlated with 31.4% of Group I cases showed metastasis to cervical lymph node as related to 47.5% of Group II. The study results are in conformity with Liang et al.[38] The HIF-1α overexpression is considered to be regulated by vascular endothelial growth factor C which consequences in lymphangiogenesis and angiogenesis and thus in cervical lymph node metastasis in OSCC.[39] The affirmative relationship among cervical lymph node metastasis and over expression of HIF-1α in OSCC is further correlated with prognosis of the patients.[39]

Therefore, our study results propose that the OSCC with OSMF is clinicopathologically distinctive subset of OSCC. Our study results signify that the carcinogenesis in OSCC without OSMF is chiefly related with various forms of tobacco usage. The lesions in OSCC with OSMF occur by means of a diverse and precise molecular pathway may be with the confounding effects associated with major etiological agents, areca nut and tobacco. This culminates into lesions with better grade of tumor differentiation, fewer probabilities of metastases to lymph nodes as well as with early clinical TNM stage. All these factors are responsible for better prognosis in OSCC with OSMF. These observations possibly will offer some basis for the development of distinct management protocol for this subset of OSCC.

 Conclusions



Considering the analysis of biomarkers, HIF-1α and CD-105 in OSCC with and without OSMF cases, it can be concluded that the OSCC with OSMF is not only clinicopathologically distinct subtype of OSCC but also diverse in its molecular pathogenesis. This distinctiveness could be attributed to the preexisting modifications of ECM in the form of fibrosis seen in Group I. These variations could be attributed to difference in clinical manifestations of the disease, i.e., clinical stages, histopathological grades and metastasis to lymph node. Therefore, it is postulated that the addition of areca nut carcinogens modifies the carcinogenic pathway and thereby alters the response of connective tissue to the biomarkers CD105 and HIF-1α. This distinct expression of HIF-1α and CD105 in OSCC with and without OSMF may be an important prognostic indicator for the outcome in OSCC.

Limitations

We recommend future multi-centric study in large-scale population to better understand the clinicpathological trend followed by OSCC with OSMF cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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