A novel histopathological subclassification of oral submucous fibrosis based on epithelial keratinization: A proof-of-concept pilot observation

EVALUATION OF CANCER STEM CELL MARKER, BMI-1 EXPRESSION IN ORAL SUBMUCOUS FIBROSIS WITH AND WITHOUT MALIGNANT TRANSFORMATION

Oral squamous cell carcinoma (OSCC) in the background of oral submucous fibrosis (OSMF) is one of the most common presentations of oral cancer among Asian population. OSCC arising in the background of OSMF (OSCC with OSMF) has been a topic of interest among researchers recently and a few studies have considered this to be a distinct clinicopathological entity. This systematic review analyses the demographic and clinicopathological variations of OSCC with OSMF from conventional OSCC to evaluate the distinctiveness of OSCC with OSMF. A comprehensive search from PubMed, Google scholar and manual search were carried out and 4 articles were retrieved and analysed systematically. Out of the total 377 OSCC with OSMF cases and 542 conventional OSCC, males were found to be predominantly affected (82.7% and 73.6%). 47% of the OSCC with OSMF cases were well differentiated squamous cell carcinomas as against 33.4% in conventional OSCC. Lymph node metastases were seen predominantly in conventional OSCC (49.1%) than OSCC with OSMF cases (40.7%). OSCC with OSMF were more prevalent in males and showed better tumour differentiation and lesser lymph node metastasis. Even though the present results inculpate OSCC with OSMF as a distinct clinicopathological entity, there is a dire need for thorough investigation.

Introduction:Oral submucous fibrosis is a chronic debilitating condition with potential for malignant transformation. Squamous cell carcinoma arising from a background of oral submucous fibrosis presents clinically as a distinct disease due to different etiopathogenesis.Methodology:This prospective case series describes thirty cases of oral squamous cell carcinoma (OSCC) alongside oral submucous fibrosis (OSF). Patient clinical data were recorded including type and duration of habits, site of tumor, size, histological grading and nodal status.Results:A total of 76% cases were reported in males and 24% in females. A total of 73.3% cases had a history of use of gutka of which 16% used only arecanut or gutka while the remaining used gutka along with smoking and quid habits and 26.7% cases smoked tobacco products or used smokeless tobacco. Primary site of presentation was buccal mucosa and seven cases of carcinoma at retromolar trigone (RMT) altogether accounting for 66% of the cases. 53.3% cases reported were advanced tumour T4 lesions, 10% T3 lesion, 30% reported as T2 lesions and 6.7% T1 lesion. 55% of cases showed nodal involvement of different level and 46.5% cases were N0. About 60% of cases were histologically well differentiated squamous cell carcinoma.Conclusion:Carcinoma arising from a background of oral submucous fibrosis follows a distinct clinical presentation. Malignant transformation occurs in younger age group and with better histological grading.

Evaluation of stromal mucin expression in oral submucous fibrosis and its progression to oral squamous cell carcinoma.

Expression of proliferating cell nuclear antigen (PCNA) in oral submucous fibrosis, oral epithelial hyperkeratosis and oral epithelial dysplasia in Taiwan.

Oral submucous fibrosis (OSMF) is a chronic progressive, scarring disease affecting oral, oropharyngeal, and sometimes the esophageal mucosa. It is characterized by the progressive fibrosis of the submucosal tissue. The pathogenesis of OSMF has been directly related to the habit of chewing areca nut and its commercial preparation, which is widespread in Indian subcontinent and Southeast Asia. The areca nut has been classified as a "group one human carcinogen." Oral squamous cell carcinoma in the background of OSMF is one of the most common malignancies in South and Southeast Asian countries. Malignant transformation has been reported in 7%-12% cases of OSMF. Histopathological spectrum of OSMF includes the apparent alterations observed in the epithelium and connective tissue. Epithelial atrophy and sometimes epithelial hyperplasia with or without dysplasia are the peculiar alterations seen in the epithelium. In the connective tissue, there is extracellular matrix remodeling which results in excessive collagenization. Further cross-linking of collagen leads to hyalinization which makes the collagen resistant to proteolysis. Owing to fibrosis in the connective tissue, there is narrowing of blood vessels which further results in compromised blood supply to the local tissue milieu, that is, hypoxia. This tissue hypoxia elicits angiogenesis which may result in the malignant transformation of OSMF. Perpetual irritation of areca nut and its constituents to the oral mucosa leads to upregulation of pro-inflammatory cytokines and further juxtaepithelial inflammation. Thus, these coordinated reactions in epithelium and connective tissue leads the OSMF toward malignant transformation.

Background: Oral submucous fibrosis (OSMF), now worldwide acknowledged as the disease of “Southeast Asia and Indian subcontinent”, has the utmost malignant transformation prevalence amongst oral precancerous disorders. Increased vascularity that is neoangiogenesis has been observed in the superficial connective tissue region of pre-cancerous lesions showing dysplasia. This could be an initial occurrence of the carcinogenesis process. The aim of this study will be to analyse neoangiogenesis by examining immunoexpression of CD105 in OSMF, and OSCC with OSMF cases. Methods: The project will comprise 30 normal oral mucosa samples (group I), 30 clinicopathologically diagnosed cases of OSMF (group II), and on the basis of association of OSMF, 30 surgically operated and histopathologically diagnosed cases of OSCC associated with OSMF (group III). Hematoxylin and eosin stains will be used for routine staining procedures and immunohistochemistry for the expression of CD105. Oral epithelial dysplasia (OED) cases of OSMF will be categorized into two groups, low-risk epithelial dysplasia (LRED) and high-risk epithelial dysplasia (HRED). The micro vessel density (MVD), total microvessel area (TVA), and mean microvessel area (MVA) are within and surrounding the tumor tissue sections immunostained with the CD105 antibody will be determined. ANOVA will be applied for evaluation of the mean scores of MVD, TVA, and MVA of groups II and III. The obtained score will be compared with different parameters of OSCC (TNM stage, lymph node metastasis, and histopathological grades). Conclusions: We postulate the progressively increased vascularity with the disease progression from LRED to HRED and further its transformation to invasive oral squamous cell carcinoma This increased vascularity will be evident by enhanced MVD, TVA and mean MVA, which is expressed by CD105 immunoexpression. This observation will emphasize the significance of neoangiogenesis in cases of OSMF with epithelial dysplasia and its further progression to OSCC.

To evaluate the incidence of oral squamous cell carcinoma concomitant with oral sub mucous fibrosis in central India and to correlate precipitating factors associated with oral submucous fibrosis and oral squamous cell carcinoma. This paper also aims to study the incidence of oral squamous cell carcinoma arising secondary to untreated oral submucous fibrosis. Two hundred and twenty five cases of oral squamous cell carcinoma and one hundred and nineteen cases of oral submucous fibrosis of various regions in oral cavity were included in the study. All the included cases were clinically and histopathologically diagnosed and retrospective data was retrieved. In the present study of 119 patients of oral submucous fibrosis, 97.4% were found to have betel nut chewing habit. Incidence of malignant transformation to oral squamous cell carcinoma in patients of untreated oral submucous fibrosis was found to be 4.2% in the present study. The incidence of oral cancer concomitant with oral submucous fibrosis was found to be 25.77%, which is statistically significant. From the present study, it is evident that the malignant potential of OSF is underestimated. However, considering the small sample size and the fact that the study was carried out in a small geographical area, further study with a larger sample size and longer duration of follow up on a multicentric basis may be required to reveal the actual malignant potential of the disease.

Connective tissue growth factor (CTGF), a matricellular protein of the CCN family of extracellular matrix-associated heparin-binding proteins, is highly expressed in various organ fibrosis and several malignant tumors. Although a few studies have been conducted using CTGF in oral submucous fibrosis (OSF) and oral squamous cell carcinoma, no study has demonstrated its relation with various stages of OSF and its malignant transformation. The present study investigated the possible role of CTGF in the pathogenesis of OSF and its malignant transformation by using immunohistochemistry.Ten formalin-fixed paraffin-embedded tissue blocks, each of Stage 1 OSF, Stage 2 OSF, Stage 3 OSF, Stage 4 OSF, well- differentiated squamous cell carcinoma (WDSCC) with OSF and WDSCC without OSF were stained for CTGF by immunohistochemistry. Ten cases of healthy buccal mucosa (NOM) were included as controls.The present study demonstrated a statistically significant expression of CTGF in the epithelium and connective tissue of OSF and WDSCC with and without OSF cases against its complete absence in NOM. We observed an upregulation of CTGF expression from NOM to various stages of OSF to WDSCC with or without OSF.A gradual upregulation of the CTGF expression in various stages of OSF to WDSCC (with and without OSF) against its complete absence in NOM suggests that CTGF plays an important role in the pathogenesis of OSF and its malignant transformation.

BackgroundThis study delves into the intricate landscape of oral cancer, a global concern with a high incidence in Asian countries. We focus on oral squamous cell carcinoma (OSCC), primarily driven by the consumption of betel nut and its derivatives. OSCC often arises from premalignant lesions like oral submucous fibrosis (OSF). In Pakistan, OSCC is prevalent among men due to various addictive substances, including smokeless tobacco and chewing materials. Mutations in tumor suppressor genes, such as TP53 and p21, play crucial roles in this malignancy’s development. We also explore the involvement of TUSC3 gene deletion in OSCC and OSF.MethodsIn this study we investigated demographics, TUSC3 gene expression, deletion analysis, and TP53 and p21 genetic alterations in OSCC and OSF patients (blood and tissue of 50 samples in each condition) who had tobacco derivates usage history. The association analysis was carried out mainly through PCR based genotyping.ResultsThe study’s patient cohort (OSCC and OSF) displayed a wide age range from 13 to 65 years (Mean = 32.96 years). Both conditions were more prevalent in males, with a male-female ratio of approximately 2.5:1. Chewing habits analysis revealed high frequencies of gutka use in both OSF and OSCC patients. TUSC3 expression analysis in OSCC cell lines indicated significant downregulation. Genotyping showed no TUSC3 deletion in OSF cases, but a deletion rate of over 22% in OSCC tissue samples. Analysis supported a significant association of TUSC3 deletion with OSCC development but not with OSF. Polymorphism in p53 exon 4 and p21 (rs1801270) were significantly associated with both OSCC and OSF, adding to their pathogenesis. Our findings further revealed a strong correlation between TUSC3 deletion and the excessive use of tobacco and related products, shedding light on the genetic underpinnings of OSCC development.ConclusionsNotably, our study provides a crucial insight into genetic aspects underlying OSCC and OSF in response of addictive consumption of areca nut, betel quid, and tobacco derivatives. A significant association between TUSC3 deletion and OSCC development, along with polymorphisms in TP53 and p21, underscores the importance of further research into the molecular mechanisms driving oral cancer progression for improved diagnosis and treatment outcomes.

Aim: To examine and compare cytomorphometric changes in the keratinocytes obtained from buccal mucosa of oral submucous fibrosis (OSF) cases in different clinical stages with healthy subjects and oral squamous cell carcinoma (OSCC) cases. Materials and Methods: Buccal mucosal smears of OSF cases [ n = 30], OSCC cases [ n = 30] and age-sex matched healthy controls [ n = 30] were stained with Papanicolou stain and observed under light microscope (40x objective magnification) and 100 cells in each case were analysed cytomorphometrically using an image analyser. The average nuclear area (NA), cell area (CA), ratio of nuclear area/cell area, nuclear diameter (ND), cell diameter (CD) and ratio of nuclear diameter/cell diameter was obtained for each case. One-way ANOVA and Tukey-HSD procedure ( P < 0.05) were used to analyze all the parametric variables. Results: The comparison of mean values of the NA, CA, NA:CA, ND, CD, ND:CD shows statistically significant difference among the healthy, OSF and OSCC groups [ P < 0.05]. OSF group showed significant increase in nuclear dimensions and N/C ratio and significant decrease in cell dimensions compared to healthy group ( P < 0.05). Among the parameters analysed ND:CD and NA:CA showed a highly statistically significant difference between the OSF and healthy group ( P < 0.001). Conclusions: There are significant alterations in the cell and nuclear dimensions of the buccal mucosal cells in OSF patients. These alterations could be attributed to usage of various tobacco and areca nut preparations and due to the mucosal changes (atrophic epithelium, high epithelial turnover) in the OSF. Atrophic epithelium, in OSF is envisaged to predispose malignant transformation with persistent exposure oral carcinogens. As the mean values of CA, NA:CA in stage IV OSF are close to OSCC cases, it strengthens the view that advancement of fibrosis increases the risk of development of epithelial dysplasia.

Better grade of tumor differentiation of oral squamous cell carcinoma arising in background of oral submucous fibrosis

In 2022, global oral squamous cell carcinoma (OSCC) incidence was 389,846 cases, with 188,438 deaths (GLOBOCAN). In India, it ranked 2nd with 143,759 cases and 79,979 deaths, and a 5-year prevalence of 370,106 cases. High OSCC rates are associated with oral leukoplakia, erythroplakia, and oral submucous fibrosis (OSMF), with malignant conversion rates of 1.1%-40.8% for leukoplakia, 19.9%-45% for erythroplakia, and 6% for OSMF. Central India has the highest oral cancer incidence, 19.2% in males and 7.6% in females. Limited research highlights the need for public health interventions; our study offers key epidemiological insights from a tertiary care center. The study investigates the prevalence and epidemiology of oral leukoplakia, erythroplakia, and OSMF among tobacco and areca nut users. This prospective observational study was conducted at the Govt Dental Institute, of Central India, from September 2022 to March 2023, with ethical clearance (No. 161/IEC/SS/2022). A purposive sampling approach targeted individuals with smokeless tobacco, smoking, or areca nut consumption. Oral cavity screenings were conducted, classifying leukoplakia, erythroplakia, and OSMF using established clinical criteria. The data were analyzed using SPSS 25.0, with significance set at p < 0.05. Among 28,736 patients, 5,428 had a history of tobacco or areca nut consumption, and 411 were diagnosed with OPMDs (Oral Potentially Malignant Disorders), yielding an overall prevalence of 7.57%. OSMF was the most common disorder (5.30%), followed by oral leukoplakia (2.22%) and erythroplakia (0.036%). The most prevalent habit was areca nut and smokeless tobacco consumption (71.53%). OSMF Grade IV had the highest prevalence (36.79%). The prevalence of Oral Potentially Malignant Disorders in this study (7.57%) exceeds global averages, highlighting the impact of tobacco and areca nut consumption in Central India. OSMF, particularly Grade IV, is more prevalent, underscoring the need for targeted public health interventions and rigorous screening for early detection and management.

Oral submucous fibrosis (OSF) is a chronic oral condition with a potential for malignant transformation. This study aims to investigate the correlation between DNA aneuploidy and dysproliferative lesions in OSF using DNA image cytometry to provide insights into cancer risk assessment. The study included patients diagnosed with OSF, OSF combined with oral leukoplakia (OLK), OSF that progressed to oral squamous cell carcinoma (OSCC), and healthy controls. Exfoliated oral mucosal cells were collected and analyzed using DNA image cytometry. Statistical analyses were conducted using SPSS 22.0 to compare the results across different groups. The study revealed that DNA image cytometry demonstrated high sensitivity and specificity for diagnosing OSCC and epithelial dysplasia. Furthermore, the frequency of abnormal DNA content in oral exfoliated cells from patients with OSF + OLK significantly increased with the grade of abnormal histopathological epithelial proliferation. Significant differences in DNA content were observed between the OSF, OSF + OLK, and OSCC groups. Additionally, patients with OSF showed no significant difference in DNA content between the buccal and tongue mucosae, but those with OSF + OLK demonstrated differences in DNA content between the OSF and OLK lesion areas. DNA image cytometry is a valuable tool for assessing cancer risk in OSF patients, particularly those with coexisting OLK. The findings suggest that OSF + OLK patients have a higher risk of cancer than those with OSF alone, providing crucial scientific evidence for predicting cancer risk and guiding early intervention strategies.

The role of platelet parameters as markers of inflammation in various diseases is now in limelight. The interaction between cancer cells and platelets is a well-established phenomenon. Oral submucous fibrosis (OSMF) is a premalignant disorder with a malignant transformation rate of 2-8%. This study aimed to evaluate platelet parameters in OSMF and oral squamous cell carcinoma (OSCC) in the background of OSMF. This cross-sectional study was performed using secondary data retrieved between January 2019 and December 2019 in the Department of Oral Pathology and the Hematology Laboratory. The data retrieved included 44 histopathologically proven OSCC in a background of OSMF (group III) and 36 OSMF (group II). The haematological parameters of these selected cases were retrieved from the Sysmex XN-1000 automated hematology analyser database. A control group (group I) comprises 50 subjects with normal (negative/unflagged) haematological parameters. All data were statistically analysed using SPSS 20.0. The significance level of tests was set at 5%. The mean platelet volume (MPV) (9.60 [±0.95] P < 0.001), platelet distribution width (PDW) (10.45 [±1.9], P < 0.001), platelet large cell ratio (PLCR) (21.70 [±7.98], P < 0.001), and the ratio of mean platelet volume to total platelet count (MPV/PLT) (0.03 [0.01], P < 0.001) were lower in group III when compared to the other two groups. Platelet parameters may be used as indices in the OSCC in the background of OSMF. However, large-scale prospective studies are necessary to evaluate the utility of these parameters during the malignant transformation of OSMF, thereby encouraging prompt treatment to prevent morbidity and mortality.