Oral Oncology 121 (2021) 105451

Contents lists available at ScienceDirect

Oral Oncology
journal homepage: www.elsevier.com/locate/oraloncology

Overview of oral cavity squamous cell carcinoma: Risk factors,

mechanisms, and diagnostics
Ambika Chamoli, Abhishek S. Gosavi, Urjita P. Shirwadkar, Khushal V. Wangdale,
Santosh Kumar Behera, Nawneet Kumar Kurrey, Kiran Kalia, Amit Mandoli *
Department of Biotechnology, National Institute of Pharmaceutical Education and Research-Ahmedabad (NIPER-A), An Institute of National Importance, Government of
India, Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Palaj, Opp. Air Force Station, Gandhinagar 382355, Gujarat, India

A R T I C L E I N F O A B S T R A C T

Keywords: Oral cavity squamous cell carcinoma (OCSCC) is the most common malignancy of the oral cavity. The substantial
Oral cavity squamous cell carcinoma (OCSCC) risk factors for OCSCC are the consumption of tobacco products, alcohol, betel quid, areca nut, and genetic
Oral cavity cancer (OCC) alteration. However, technological advancements have occurred in treatment, but the survival decreases with
Risk factor
late diagnosis; therefore, new methods are continuously being investigated for treatment. In addition, the rate of
Genetic alterations
secondary tumor formation is 3–7% yearly, which is incomparable to other malignancies and can lead to the
Signaling
Diagnostic disease reoccurrence. Oral cavity cancer (OCC) arises from genetic alterations, and a complete understanding of
Treatment the molecular mechanism involved in OCC is essential to develop targeted treatments. This review aims to update
the researcher on oral cavity cancer, risk factors, genetic alterations, molecular mechanism, classification,
diagnostic approaches, and treatment.

Introduction international, multicentre, pooled study has focused on the five-year

Oral cavity cancer (OCC) is categorized under head and neck cancer
(HNC) and holds the sixteenth position in malignancy worldwide [1]. In
2020, lip and OCC accounted for 377,713 incident cases and 177,757
mortality worldwide [2]. OCC is the most common malignancy in South-
East Asia (India, Sri Lanka, Pakistan, Bangladesh, and Taiwan) and the
Pacific regions (Papua New Guinea and Melanesia) due to the habit of
betel nut chewing [3]. OCC is defined as malignant neoplasia of the oral
cavity and includes subsites buccal mucosa, floor of mouth, anterior
tongue, alveolar ridges, retromolar trigone, hard palate, and inner part
of lips [4]. More than 90% of OCC originates from the squamous tissues,
hence widely known as oral cavity squamous cell carcinoma (OCSCC)
[3,5]. The contributing factors for the development of OCC are the
consumption of tobacco products in smoke or smokeless form. More­
over, low socioeconomic status, self-negligence, and lack of awareness
are the key factors for OCC to occur [6]. OCC is generally observed in
people aged above 40 years compared to younger ones. Worldwide, a
higher prevalence of OCC occurs in males than females, 5.8 vs. 2.3 per
100,000 [7].
With the advancement in diagnostics and therapeutics, the five-year
survival rate of OCSCC has improved remarkably. A retrospective,
survival of OCSCC patients who underwent surgery alone or surgery
with adjuvant radiotherapy. From 1990 to 2011, the five-year overall
survival increased from 59% to 70% [8]. The survival rate can vary due
to anatomical location of various subsites, stage, grade of the OCC, age
at diagnosis, treatment, and comorbidity [9]. The percentage of diag­
nosed cases and mortality cases also varies according to the geograph­
ical location. Asia has the highest percentage of cases diagnosed (64.2%)
and mortality (73.3 %), while Oceania has the lowest patients diagnosed
(1.3%) and mortality (0.56%) [10]. In South America, Central Eastern
and Northern Europe, human papillomavirus infections (HPV) are
responsible for a growing percentage of OCC among young people [11].
Risk factors
OCC is linked with various factors, including tobacco consumption in
the form of smoke and smokeless tobacco (SLT) products, alcohol, and
human papillomavirus (HPV) (Fig. 1). OCC can also occur at an early age
because of the family history of some genetic alternations in the genome,
such as Xeroderma pigmentosum, Fanconi anaemia, Dyskeratosis
congenital [12].

* Corresponding author.
E-mail address: amitmandoli@niperahm.res.in (A. Mandoli).

https://doi.org/10.1016/j.oraloncology.2021.105451
Received 6 April 2021; Received in revised form 1 July 2021; Accepted 4 July 2021
Available online 28 July 2021
1368-8375/© 2021 Elsevier Ltd. All rights reserved.
A. Chamoli et al.
Smoke and smokeless tobacco products
Smokers are 8.4 times more prone to develop OCC as compared to
non-smokers [13]. SLT consumers are five to seven times more prone to
OCC than non-user [14]. South and South-East Asia account for >85% of
the burden daily adjusted life years (DALYs) loss due to SLT use [15].
SLT forms include pan masala, tobacco chewing, betel quid, areca nut,
gutka, khaini, etc. Betel quid and areca nut chewing with or without
tobacco increase the risk for OCC, therefore, classified group 1 carcin­
ogen [16,17]. The smoke, SLT products, betel quid, and areca nut
contain cancer-causing chemicals, thereby increasing the chances of
OCC in the users [18,19].
Alcohol
According to International Agency for Research on Cancer (IARC),
alcohol is classified as a group 1 carcinogen. Its intake has been asso­
ciated with an increased risk of cancer in the oral cavity, pharynx, lar­
ynx, esophagus, liver, colorectal cancer and, female breast cancer
[20,21]. The possible mechanism of alcohol-associated carcinogenesis is
that the alcohol dehydrogenase (ADH) enzyme oxidizes ethanol into
acetaldehyde, an intermediate metabolite that reacts with DNA and
forms DNA adducts. These adducts either cause mutation or inhibit DNA
synthesis and thus induce cancer [21,22].
Alcohol is an independent factor, but when taken together with to­
bacco, both act synergistically and increase the risk of developing OCC
35 fold [23]. Furthermore, ethanol also acts as a solvent for many car­
cinogens, thereby increasing the penetration of various chemical entities
from tobacco products, diets, etc., into the oral cells [24].
Human papillomavirus
Two to eight percent of OCCs are caused by the human papilloma­
virus (HPV) infection [25]. HPVs are small 52–55 nm, non-enveloped
circular DNA viruses enclosed by a protein capsid. HPV16/18 express
E6 and E7 oncoprotein that inactivates essential tumor suppressor genes
(TSGs) p53 and pRb, resulting in an aggressive division of cells to form
cancer [25].
Genetic alterations
Genetic studies reveal a close association between OCC development
and the accumulation of genetic alterations. Various chromosomal al­
terations are associated with OCC [26]. Oral epithelial dysplasia
frequently leads to the transformation of precancerous lesions into
invasive OCC. The deletion on 3p chromosome in 3p25.3-p26.1, 3p25.1-
p25.3, 3p24.1, 3p21.31-p22.3, 3p14.2 and 3p14.1regions result in
dysplasia with frequency ranging between 56% and 78%; while OCC
showed more than 90% of loss in these regions. Gains in 3q26, 8q22.3,
8q11-q21, 8q24, 11q13, 11q13.2-q13.4 regions are detected frequently
in high-grade dysplasia [27]. Allelic loss of 3p including the 3p13-p14,
3p21.2-p21.3 and 3p25 locus is present around 74–81% deletion and are
related to tobacco consumption [28].
2
Oral Oncology 121 (2021) 105451
Fragile Histidine Triad (FHIT) is a TSG on chromosome 3p14.2 re­
gion in which damage caused by carcinogen leads to aberrant tran­
scription of this gene. FHIT is suppressed in 65% of OCC and is
associated with poor survival [29]. In addition, FHIT methylation with
p16 methylation has been reported in smokers with squamous cell lung
carcinoma, suggesting that FHIT and p16 expression are coregulated by
methylation in OCC in individuals exposed to tobacco smoke [30,31].
Chromosomal deletions at 2q21-24, 2q33-35 and 2q37 affect TSGs,
including LRP1B, CASP8, CASP10, BARD1, ILKAP, PPP1R7, and ING5.
Loss of heterozygosity (LOH) at chromosomal loci 13q, 17p, 9p21, is
associated with premalignant oral lesions and early carcinomas. Other
aberrations, such as allelic losses at 5q21-22, 22q13, 4q, 11q, 18q, and
21q, are associated with the advanced tumor stage.
Amplification in chromosome arms 8q22-q23 (EIF3E) and 8q24.21
(MYC) occurs in mild dysplasia, and gain in the whole 8q arm is detected
in the invasive OCC. The co-amplification of the EIF3E and RECQL4
gene was observed with an alcohol-induced carcinogen. The chromo­
some 8 deleted regions found in OCCs are 8p21, 8p22, and 8p23 [32].
TP53 is the most frequently mutated gene in various cancer [33]. In
OCC, the frequency of TP53 mutation ranges from 35.9% to 81% and is
found in only HPV-negative subgroups [33,34]. Tobacco smoking in­
duces C > A transversion, leading to mutations in the coding sequence of
TP53 [35,36]. TP53 mutation frequency is followed by the CDKN2A,
HRAS, PIK3CA, SMARCB1, KIT, EGFR, BRAF, STK11, ABL1, and RB1
gene mutations in OCC [37,38].
PIK3CA is an oncogene mutated in OCC. PIK3CA is reported to be
mutated in 8% of HPV-negative tumors and 21% of HPV-positive tumors
[39]. Furthermore, PIK3CA is found to be mutated in stage IV of OCC
and results in poor survival. The commonly associated mutational sites
of PIK3CA are present in exon 9 and 20 of the tyrosine kinase domain
[40].
NOTCH1 is mutated in OCC (54%) and preneoplastic lesions (60%)
in the Asian population (especially China) [41]. Moreover, initiation and
progression of OCC are associated with mutation frequency ranging
from 22% to 30% in the NOTCH1 gene [34].
FAT1, a TSG, is located on chromosome 4q35.2 and belongs to the
cadherin superfamily [35]. FAT1 is involved in cell migration and in­
vasion, and deletion of FAT1 gene in OCC inhibited cancer cell migra­
tion and invasion by altering the translocation of β-catenin [42],
suggesting that FAT1 could be used as a drug target for the treatment of
OCCs.
Due to regular tobacco chewing habits in South East Asia, >30% of
mutations are found in the Ras genes (specially H-Ras), which are
involved in the MAPK pathway [43]. The frequency of PIK3CA and
HRAS mutation is the same in the Asian and Caucasian populations
despite their habit of smoking betel quid chewing and alcohol intake
[41]. Another mutated gene is FTH1P3, which promotes the prolifera­
tion, migration, and invasion of OCC by associating Wnt-βcatenin via
PI3K/Akt/GSK-3β signaling [44].
KMT2D (histone-lysine N-methyltransferase) and NSD1 (histone-
lysine N-methyltransferase) are TSGs associated with epigenetic modi­
fications, such as histone modifications, and involved in OCC [45].
Enzymes that add a methyl group to cytosine bases in the CpG
Fig. 1. Schematic representation of cancer. OSCC is
a multistep process. Normal oral mucosal epithelial
cells are exposed to risk factors like tobacco,
alcohol, HPV resulting to undergo an epithelial-
mesenchymal transition (EMT). This EMT enables
the epithelial cell to acquire mesenchymal traits
which include increased production of extracellular
matrix (ECM) components, migration, invasion,
angiogenesis, lymphogenesis, and inhibition of
apoptosis. (Abbreviations: OSCC – Oral squamous
cell carcinoma, EMT- epithelial-mesenchymal tran­
sition, ECM-extracellular matrix).
A. Chamoli et al.
dinucleotides are DNA called methyltransferases (DNMTs). Activities of
DMNTs are frequently altered in cancer; hypermethylation in the TSG
promoters leads to silencing of their expression, whereas hypo­
methylation leads to genetic instability and oncogene activation [46].
Altered signaling in oral cavity cancer
A normal healthy cell is under controlled cell division, differentia­
tion, and apoptosis; thereby, homeostasis of the cell is maintained. But
the cancer cell loses its regulation, undergoes undefined cell prolifera­
tion, and escapes apoptosis by various mechanisms, including sustaining
proliferative signaling [43,47].
The ErbB family of receptor tyrosine kinases consists of a subfamily
of four closely related receptor tyrosine kinases: EGFR (ErbB-1), HER2/
neu (ErbB-2), Her 3 (ErbB-3), and Her 4 (ErbB-4). Normal cells express
epidermal growth factor receptor (EGFR) in a controlled manner,
whereas it is overexpressed in cancer cells [48]. EGFR allows the oral
squamous cells to undergo epithelial-mesenchymal transition (EMT)
[49]. Studies have identified a relationship between the overexpression
of EGFR, HER2, or HER4 related to poor OCC patient survival [50].
TSGs regulates cell growth, cell cycle, cellular differentiation, DNA
repair, and apoptosis. Mutations in TSGs lead to the development of
cancer, and 60–80% of TSGs mutations are detected in the TP53 gene
[51]. The tumor microenvironment consists of fibroblasts, immune cells,
endothelial cells (ECs), and other cells. Cells of the tumor microenvi­
ronment produce tumor-promoting factors, leading to growth, survival,
and metastasis of tumor cells. In addition, factors released by the tumor
microenvironment cells promote angiogenesis in tumor [52].
In normal cells, E-cadherin maintains the cell–cell contact and
integrin mediates cell–cell and cell-extracellular contacts. The loss of E-
cadherin function contributes to increasing invasion, proliferation, and
metastasis in OCC. Cancer cells undergo epithelial-mesenchymal tran­
sition (EMT), by downregulating E-cadherin and up-regulating N-cad­
herin, desmin, and vimentin, resulting in distal metastasis [53]. Several
signaling pathways are involved in EMT, such as transforming growth
factor (TGF-β), fibroblast growth factor (FGF), hepatocyte growth factor
(HGF), Wnt, Notch, platelet-derived growth factor (PDGF), and Hedge­
hog [48,54,55].
Tumor cells demand high glucose and oxygen to thrive, which is
supported by developing the new blood vessels by vasculogenesis and
angiogenesis [54]. Vascular endothelial growth factors (VEGFs) -A, -B,
-C, -D, and -E are involved in forming new blood vessels. It has been
reported that overexpression of VEGF-C is associated with lymph node
metastasis, recurrence, and poor prognosis in OCC [56,57]. Therefore,
VEGF-C may contribute to establishing new therapies for OCC patients
with lymph node metastasis and recurrence.
MAPK signaling
Mitogen-activated protein kinases (MAPKs) are a group of serine and
threonine protein kinases that regulates cellular proliferation, cell
migration, metastasis, apoptosis, and angiogenesis [58]. MAPK phos­
phorylation upregulates the expression cyclin D1, which is responsible
for the progression of the cell cycle from the G1 phase to the S phase and
thus drives cell proliferation, leading to OCC. Additionally, activated
MAPK prevents the expression of cell cycle inhibitor proteins, including
p27KIP, and contributes to the inhibition of extrinsic and intrinsic cell
death pathways [43,16].
WNT signaling
Beta-catenin (β- catenin) plays a central role in the WNT pathway,
which regulates various biological processes such as cell division, cell
proliferation, cell migration, and cell maintenance [59]. Overexpression
of Wnt3 ligand in OCSCC leads to the proliferation and invasion of OCC
cells. An active EGFR signal is known to decrease membrane-bound
3
Oral Oncology 121 (2021) 105451
β-catenin, increasing the nuclear accumulation of β-catenin. Loss of β-
catenin from the cell membrane is observed in around 50% of oral
carcinomas and is related to poor histological grade and increased
lymph node involvement. An increased level of β-catenin inside the
nucleus leads to tumor invasion and metastasis of OCC [60]. Moreover,
aberrant expression of β- catenin is related to dysplasia and ranges to 66
% in OCSCC and is related to poor prognosis. The increased expression of
CD1 oncogene, a target of β- catenin has been observed in OCC and is
linked to dysplasia and leukoplakia [61,62] (Fig. 2).
PI3K/AKT/mTOR signaling
Phosphatidylinositol 4,5-bisphosphate 3-kinase(PI3K) signaling
pathway controls various cellular activities like protein synthesis,
autophagy, cell cycle regulation, glycogen metabolism, fatty acid syn­
thesis, cell apoptosis, cell proliferation, angiogenesis, and cell migration
[63,64]. PI3K phosphorylates membrane-bound phosphatidylinositol
4,5-bisphosphate (PIP2) to phosphatidylinositol (3,4,5)-trisphosphate
(PIP3), which lead to activation of AKT [65]. Dephosphorylation of PIP3
leads to the formation of PIP2, which is catalysed by phosphatase and
tensin homolog (PTEN). The loss of PTEN function results in increased
concentrations of PIP3, leading to hyperactivation AKT; hence, PTEN act
as a TSG. Recently it is found that 56% of OCC show a loss of PTEN
protein expression [66]. Increased expression of BCL-2 and loss of PTEN
expression are associated with poor differentiation of tumor, lymph
node involvement, and late stages in OCC [66]. mTOR is a downstream
target of AKT, leading to tumor development, invasion, metastasis, and
angiogenesis. Over-expression of phosphorylated mTOR(p-mTOR) has
been associated with a poor prognosis of OCC [67] (Fig. 3).
Diagnostics
Most oral malignancies are diagnosed in the late stage, resulting in a
high death rate for oral cancer patients. Therefore, early diagnosis not
only helps to prevent disease complications but also to provide a healthy
lifestyle to the patient.
Visual and histopathological examination
The oral cavity is easy to access and examine. Visual screening helps
identify the clinical features in an asymptomatic person, leading to an
earlier diagnosis and better treatment [68,69]. The conventional visual,
oral examination, and palpation of suspicious lesions constitute a
screening method for OCC [70]. A population-based oral, visual
screening program for individuals who had habits of betel quid chewing,
cigarette smoking, or both revealed that the screened group had a higher
early-stage detection of OCC than the unscreened group [71]. However,
visual screening helps to an earlier diagnosis but can lead to underdi­
agnosis or misinterpretation [72]. To confirm OCC, a visual screening is
followed by a histopathological diagnosis of the tumor biopsy [73]. The
biopsy can be obtained either by surgical resection or fine-needle aspi­
ration cytology [74,75]. Fine Needle Aspiration Cytology (FNAC) has
been a valuable tool in diagnosing tumors located at the salivary gland
[76]. FNAC is rapid, safe, simple, minimally invasive, and re-aspiration
can be done if required [77]. Biopsies are analyzed histopathologically
using haematoxylin and eosin staining to identify the morphological
changes in the tissue to diagnose tumor. The constraint of the histo­
pathological approach is the quantity of biopsy specimens required from
the malignant and normal tissue regions [78,79] and the expected
outcome may vary with the skills and knowledge of the pathologist.
Toluidine blue (TB) staining
Toluidine blue (TB) is a basic dye with a high preference for the
components of acidic tissue (sulphates, carboxylates, and phosphate
radicals). It stains tissues rich in nucleic acids; therefore, TB-stained
A. Chamoli et al. Oral Oncology 121 (2021) 105451

Fig. 2. Schematic representation of WNT signalling

pathway. A frizzled (FZD) receptor is activated by
the Wnt ligand inducing the β-catenin translocation
from the cytoplasm to the nucleus. In absence of a
WNT ligand, β-catenin constantly gets degraded by
the destruction complex which is comprised of
glycogen synthase kinase 3β (GSK3β), adenomatosis
polyposis coli (APC), axin, and casein kinase-1
(CK1). The β- catenin is phosphorylated by GSK3β
and create a binding site for E3 ubiquitin ligase
which induces proteasomal degradation of β- cat­
enin. Thus, β- catenin is prevented for translocation
to the nucleus, thereby inhibiting the gene expres­
sion. Upon Wnt binding to the FZD receptor which is
bound to disheveled (DSH) and forms the complex
with lipoprotein receptor-related protein (LRP)
resulting destruction complex to move to the mem­
brane and hence β-catenin is stabilized. This leads to
increased accumulation of β-catenin in the cyto­
plasm and finally gets translocated to the nucleus
where it displaces the repressor Groucho from the
members of the transcription factor family (TCF).
(Abbreviations: FZD -frizzled, APC – Adenomatous
polyposis coli, CK1 – Casein kinase 1, GSK3β –
Glycogen synthase kinase 3β, TCF/LEF – T-cell fac­
tor/Lymphoid enhancer factor, FZD – Frizzled re­
ceptor, DSH – Dishevelled, LRP – Lipoprotein
related protein.)

Fig. 3. Schematic representation of PI3K-Akt-mTOR

signalling pathway. The signalling pathway is initi­
ated by epidermal growth factor (EGF) or vascular
endothelial growth factor (VEGF) that activates
tyrosine kinase to initiate a series of downstream
reactions that trigger PI3K to generate PIP3. Loss of
PTEN leads to hyperactivation of AKT. Hence acti­
vated AKT leads to phosphorylation of mTOR
thereby leading to tumor development, invasion,
metastasis, and angiogenesis. (Abbreviations: EGFR
– Epidermal growth factor, VEGFR – Vascular
endothelial growth factor, PIP2 –
Phsphotidylinositol-4,5-biphosphate, PI3K –
Phosphoinositide-3-kinase, PTEN – Phosphatase and
tensin homolog, AKT – Protein kinase-B, GRB2 –
Growth factor receptor-bound protein 2, MAPK –
Mitogen-activated protein kinase, GSK3β – Glycogen
synthase kinase 3β, NF-ƙB – Nuclear factor-kappa B,
FkHR – Forkhead transcription factor Foxo1, mTOR
– Mammalian target of rapamycin).

tissue appears dark or pale royal blue. As the cancer tissue contains minimize the occurrence of OCC [81].
significant amounts of nucleic acids, hyperplasia, and inflammatory le­
sions are stained [80] and digital color analysis helps the observers to Exfoliative cytology
identify oral lesions. TB staining helps to detect OCC at an early stage. In
addition, TB staining has a higher rate of detection and helps to Exfoliative cytology (scraping, brushing, or rinse) allows cell sample

4
A. Chamoli et al.
collection from mucosal surfaces to detect any cytological alteration
[89]. Studies have indicated that the sensitivity and specificity of
traditional exfoliative cytology are between 76.8% and 88.9% for
detecting OCC lesions. The Orcellex® brush (Rovers Medical Devices
BV., the Netherlands) has designed a device with many features like easy
availability, ease to use, minimum invasiveness, efficiency in cell
collection, and patient compliance [82,83].
Salivary biomarkers
Researchers are more focused on the non-invasive diagnosis, in that
liquid biopsy plays a crucial role in providing samples for diagnostic
purposes. Liquid biopsy utilizes saliva, a fluid enriched in DNA and
proteins that can serve as a source of diagnostic biomarkers. Salivary
biomarkers of OCC can be categorized as non-organic compound bio­
markers, peptide biomarkers, DNA/mRNA or microRNA biomarkers,
metabolomics biomarkers, and miscellaneous biomarkers [84]. To
reveal the salivary RNAs, investigators have performed the salivary
transcriptome and had identified more than 3,000 species of messenger
RNAs and over 1,000 miRNAs, which could be used to differentiate a
normal person from a diseased one [85]. In addition, several protein
biomarkers found in saliva, such as IL-1, IL-1β, IL-6, IL-8, glycoprotein
M2BP, TNF, can serve as the diagnostic biomarkers for OCC [86,87].
Although the use of saliva as a diagnostic is getting attention but has
some limitations. Issues like time points at which samples are to be
collected, lack of standardized protocols for sample collection and pro­
cessing, and a complete understanding of differential salivary bio­
markers of the disease, etc., need to be addressed for reliable, specific,
and sensitive detection of OCC.
Cell-free DNA biomarkers
In 2016, circulating tumor DNAs (ctDNAs) were approved by the US
Food and Drug Administration (FDA) for clinical use in lung cancer [88].
The ctDNA can be used as a diagnostic aid for any malignancy. ctDNA is
released by pathogenic and physiological mechanisms (apoptosis, ne­
crosis, phagocytosis, and exocytosis) from tumor cells [89]. The ctDNA
varies with the size and stages of cancer. The fraction of ctDNA is usually
very low; hence sophisticated techniques are required to analyze the
ctDNA. The methods include digital PCR (dPCR), droplet digital PCR
(ddPCR) [90], BEAMing (beads, emulsion, amplification, magnetics),
next-generation sequencing (NGS) to identify the mutational changes
associated with the disease. The ctDNAs help to detect the disease at an
early stage and hence serve as a potential source of biomarkers to detect
OCSCC [84,91,92].
Imaging technique
Identifying OCC lesions at an early stage remains a challenge. When
a normal healthy cell becomes malignant, various morphological
changes and metabolic changes occur. The imaging technique provides a
platform to capture these changes and tell us about the size, shape, and
environment of the carcinoma. These imaging techniques also help
during the follow-up of the patient before or after surgery, chemo­
therapy, or radiotherapy.
Autofluorescence imaging
Autofluorescence imaging can be used to diagnose OCC. In auto­
fluorescence imaging, fluorophores absorb light of a specific wavelength
(400–460 nm) and emit it at a higher wavelength (510 nm). Nicotin­
amide Adenine Dinucleotide (NADH) and Flavin Adenine Dinucleotide
(FAD) are fluorophores present in normal healthy cells. Fluorescence of
NADH and FAD makes healthy tissue appear as green-apple areas. In a
tumor, metabolism alternations lead to altered fluorophore distribution
within the tissue, making tumor tissue appear as a dark black area
[92,93].
5
Oral Oncology 121 (2021) 105451
FDG-PET/MRI/CT imaging
18-Fluorodeoxyglucose (FDG) is the most popular radioisotope used
in positron emission tomography (PET) imaging for tumor tissue
recognition. FDG is a glucose analog, which is absorbed by the cells and
phosphorylated to FDG-6-phosphate by hexokinase. Phosphorylated
FDG is not metabolized by the cells, thus raising the amount of FDG-6-
phosphate inside cells [94]. Imaging FDG-6-phosphate in PET scan
provides functional, biological, and anatomical imaging information
that can help to differentiate metabolically active cancerous and normal
tissue. However, the use of PET is restricted by relatively low inherent
spatial resolution, providing a blurry image [95,96]. To overcome this,
18 FDG-PET is often combined with computed tomography (CT)/mag­
netic resonance imaging (MRI) to look at tumor size and depth of in­
vasion for proper diagnosis and staging of OCC [96,97]. FDG-PET/CT is
used to examine locoregional lymph node metastases and distal metas­
tases, hence diagnosis, staging, and prognosis of the disease could be
monitored [98,99].
MRI uses a strong magnetic field to produce the three-dimensional
image, and contrasting agents are used with MRI to improve the
image depiction. MRI is useful in assessing soft bone tissue damage and
perineural invasion [100]. CT utilizes ionizing radiation and produces
cross-sectional images. CT is a standard and sensitive method for
detecting size, location, soft tissue involvement, and regional lymph
node involvement in oral cancer [99,101,102].
Next-generation sequencing
NGS provided a breakthrough to analyze the various mutations
associated with OCSCC. NGS panel showed genetic alterations in the 26
cancer-associated genes. TP53(68%) and PIK3CA (18%) were frequently
mutated genes. Other mutated genes were MET (4%), APC (4%), CDH1
(2%), and FBXW7 (2%)[103]. Ion AmpliSeq Cancer Hotspot Panel v2
targeted 2855 COSMIC mutational hotspot regions in 50 genes like
ABL1, AKT1, ALK, APC, BRAF, ERBB2, CDH1, TP53, PTEN, PIK3C, and
many more [103]. With the advances in NGS technologies, precise NGS
panels can be developed and applied in the routine diagnose of OCSCC.
TNM classification and staging of oral cavity cancer
Tumor, Lymph node, Metastasis (TNM) classification stages OCC.
The American Joint Committee on Cancer (AJCC) Staging Manual,
Eighth Edition, made some major staging modifications with the Union
for International Cancer Management on January 1, 2018, for OCC
[104]. The three major changes include: depth of invasion (DOI) is
added in the T category, extranodal extension (ENE) is added as a
staging factor to the N category except for nasopharyngeal cancer and
HPV-positive OPC, and a separate staging system is introduced for high-
risk HPV positive [104,105]. Staging is a versatile process and helps to
select an appropriate treatment for a patient (Table 1, Table 2)
[106,107].
Treatment strategies
Surgical treatment
Surgery is the main treatment for early and advance OCSCCs
[4,105]. Surgery is assisted with radiotherapy (RT)/chemotherapy (CT)
to treat patients with pathological adverse features. Adverse features
include positive margins, close margins, perineural invasion, vascular
invasion, and lymphatic invasion [4].
Chemotherapy
The use of a drug to kill or inhibit the growth of cancer cells is
chemotherapy. Chemotherapy is used as induction therapy or with ra­
diation therapy to treat some pathological stages of oral cancer [4]. CT
A. Chamoli et al. Oral Oncology 121 (2021) 105451

Table 1 plays a role in the treatment of early-stage OCC (pT1–pT2 with N1 nodal
Tumor, Lymph node and Metastasis (TNM) classification of oral cavity cancer disease) [111] or used in conjunction with surgery and/or chemo­
[adopted from American Joint Committee on Cancer (AJCC)]. therapy (NCCS guideline). A daily fractioning dose of gamma rays of
T (Tumor) 1.8–2 Gy (Gy) was given during radiotherapy, and it gets subsequently
TX Primary tumour cannot be assessed increased up to 66–72 Gy to kill the tumor cells. Radiotherapy kills
Tis Carcinoma in situ cancer cells by destroying their DNA [112,113].
T1 Tumor ≤2 cm with depth of invasion (DOI) ≤5 mm
T2 Tumor ≤2 cm with DOI >5 mm or tumor >2 cm and ≤4 cm with DOI ≤10 mm
T3 Tumour >2 cm and ≤4 cm with DOI >10 mm or Immunotherapy
Tumour >4 cm with DOI ≤10 mm
T4 Moderately advanced or very advanced local disease The immune system plays a role in fighting against cancer cells and
T4a Moderately advanced local disease:
comprises innate and adaptive immunity. Macrophages, natural killer
Tumour >4 cm with DOI >10 mm or tumor invades adjacent structure only
(e.g. through cortical bone of the mandible or maxilla or maxillary sinus or (NK) cells, dendritic cells (DC), and eosinophils are the components
skin of the face) innate immunity, while B and T lymphocytes are involved in adaptive
T4b Very advanced local disease: immunity. By increasing and decreasing cell surface antigen expression
Tumor invades masticator space, pterygoid plates, or skull base and/or and secreting factors that inactivate the immune system, cancer cells
encases the internal carotid artery
suppress and escape the immune system, promote tumor development.
N (Regional lymph node) Immunotherapy plays a role in overcoming immunosuppression in OCC.
NX Regional lymph nodes cannot be assessed
Immunotherapy drugs include monoclonal antibodies and immune
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest
checkpoint inhibitors [114].
dimension and ENE (− )
N2 Metastases in a single ipsilateral lymph node larger than 3 cm but larger than Monoclonal antibodies
6 cm in greatest dimension and ENE (− ); or metastases in multiple ipsilateral EGFR is overexpressed in many OCC cases, leading to continuous
lymph nodes, none larger than 6 cm in greatest dimension and ENE (− ); or in
activation of the downstream RAS-MEK-ERK signaling pathway. Poor
bilateral or contralateral lymph node(s), none larger than 6 cm in greatest
dimension and ENE (− ) survival and prognosis are associated with overexpression of EGFR [49].
N2a Metastases in single ipsilateral node larger than 3 cm but not larger than 6 cm The RAS-MEK-ERK signaling pathway is involved in cell proliferation,
in greatest dimension and ENE (− ) invasion, and angiogenesis. Cetuximab, a monoclonal antibody, binds to
N2b Metastases in multiple ipsilateral nodes, none larger than 6 cm in greatest
EGFR receptors and blocks the downstream RAS-MEK-ERK signaling.
dimension and ENE (− )
N2c Metastases in bilateral or contralateral lymph node(s), none larger than 6 cm
Cetuximab also activates the Fc receptor on the surface of NK cells. In
in greatest dimension and ENE (− ) response to antibody-coated target tumor cells, NK cells induce
N3 Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE antibody-dependent cell-mediated cytotoxicity (ADCC) and interferon
(− ) or Metastasis in any node(s) and clinically overt ENE (+) release. EGFR inhibitors, along with chemotherapy and radiation ther­
N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE
apy have proven promising treatments for OCCSC [115]. Nimotuzumab,
(− )
N3b Metastasis in any node(s) and clinically overt ENE (+) another monoclonal antibody, binds to the EGFR receptor and inhibits
proliferation and migration of tumor cells [49].
M (Metastasis)
cM0 No distant metastasis
cM1 Distant metastasis Immune checkpoint inhibitors
pM1 Distant metastasis, microscopically confirmed The programmed cell death-1/programmed cell death-1 ligand (PD-
1/PD-L1) pathway plays an important role in tumor invasion. Over­
expression of PD-L1 in the tumor is associated with increased tumor
Table 2 aggressiveness and poor survival. The immune checkpoint inhibitors
Staging in oral cancer. block PD-1 and PD-L1 and assist the immune system in destroying tumor
Stage 0 Tis N0 M0
cells. Anti-PD-1 inhibitors include nivolumab, pembrolizumab whereas
Stage I T1 N0 M0 atezolizumab is anti PD-L1 inhibitor [114]. Overexpression of PD-1 and
Stage II T2 N0 M0 PD-L1 have been observed in OCC [115,116]. Due to the success of
Stage III T1, T2, T3 N1 M0 pembrolizumab (anti-PD-1) and nivolumab (anti–PD-1), FDA has
T3 N0 M0
already approved it to treat OCC [117].
Stage IVA T1, T2, T3, T4a N2 M0
T4a N0, N1 M0
Stage IVB Any T N3 M0 Other therapies
T4b Any N M0
Stage IVC Any T Any N M1
Cyclooxygenase-2 (COX-2) inhibitor
Celecoxib is a selective non-steroidal anti-inflammatory drug that
with RT was implemented in pT1-pT2, N1-3 with positive margins, pT3- inhibits the COX-2 enzymes. COX-2 is overexpressed in tumors and
pT4a with positive margins, and in any extranodal extension [105]. promotes proliferation, anti-apoptosis, angiogenesis, inflammation, in­
Chemotherapeutic drugs are cytostatic or cytotoxic and either damage vasion, and metastasis [118]. Celecoxib inhibits the cell adhesion,
DNA directly or forms ROS, both of which lead to the cancer cells death movement, invasion, and metastasis of squamous cell carcinoma of the
[108]. Cisplatin, carboplatin, 5-Fluorouracil (5-FU), bleomycin, doce­ human tongue [34,119] showing the potential use of celecoxib in OCC
taxel, hydroxyurea, methotrexate are the approved chemotherapeutic treatment.
drugs for OCC [109]. 5-FU interfere with the DNA synthesis process and
induce cellular apoptosis. Docetaxel binds to tubulin, prevents tubulin Photodynamic therapy (PDT)
polymerization, inhibits spindle formation, alters mitosis, and promotes
cell cycle arrest [110]. Photodynamic therapy (PDT) is a sensitive and specific therapy to
treat OCC. PDT uses a photosensitizer drug, which generates ROS upon
activation by light of a particular wavelength. ROS induces cell death by
Radiotherapy the oxidation of lipids, amino acids, and proteins. Moreover, PDT leads
to tumor cell death by damaging tumor vasculature and activating im­
Radiotherapy (e.g., external beam radiation therapy, brachytherapy) mune responses against tumor cells [120]. FDA-approved

6
A. Chamoli et al.
photosensitizers are given orally or I.V [115]. A combination of PDT and
EGFR inhibitors showed reduced cancer cell proliferation [111], offer­
ing a combined treatment strategy.
Conclusion
Oral cavity cancer is a life-threatening disease and is linked to to­
bacco, alcohol, and HPV risk factors. The development of the disease is
associated with the accumulation of mutations. Despite the recent ad­
vancements in the treatment, the survival rate of the patient has
remained a challenge. Late diagnostics, lack of targeted therapies, and
drug resistance are the main factors behind poor survival. If diagnosed at
an early stage, OCC can be treated effectively. However, the precise
biomarkers for early diagnostics are not yet uncovered. Therefore, a
complete understanding of how genetic aberrations drive tumor phe­
notypes can be helpful to design novel diagnostics and therapeutics
approaches to treat OCCs. Moreover, raising awareness among people
for regular oral check-ups would help diagnose OCC at early stages and
minimize the incidences of OCC.
Author contributions
A.M. and K.K jointly completed the manuscript’s initial conceptu­
alization and decision on topics. Writing of the original draft was per­
formed A.C., and A.M., S.K.B. performed reviewing and editing, and N.
K., A.S.G., U.P.S., and K.V.W prepared all figures and tables. All authors
further revised the final version of the manuscript. All authors have read
and agreed to the published version of the manuscript.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
References
[1] Global Cancer Observatory. https://gco.iarc.fr/ (accessed June 24, 2021).
[2] Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al.
Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality
Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021;71(3):
209–49. https://doi.org/10.3322/caac.v71.310.3322/caac.21660.
[3] Rivera C. Essentials of oral cancer. Int J Clin Exp Pathol 2015;8:11884–94.
https://doi.org/10.5281/zenodo.192487.
[4] Network NCC. NCCN Head and Neck Cancer Series: Oral cancer. NCCN Global
Guidel 2018:169–73.
[5] Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral
Oncol 2009;45(4-5):309–16. https://doi.org/10.1016/j.
oraloncology.2008.06.002.
[6] Reich M, Licitra L, Vermorken JB, Bernier J, Parmar S, Golusinski W, et al. Best
practice guidelines in the psychosocial management of hpv-related head and neck
cancer: Recommendations from the european head and neck cancer society’s
make sense campaign. Ann Oncol 2016;27(10):1848–54. https://doi.org/
10.1093/annonc/mdw272.
[7] Nocini R, Lippi G, Mattiuzzi C. Biological and epidemiologic updates on lip and
oral cavity cancers. Ann Cancer Epidemiol 2020;4:1. https://doi.org/10.21037/
ace.2020.01.01.
[8] Amit M, Yen T-C, Liao C-T, Chaturvedi P, Agarwal JP, Kowalski LP, et al.
Improvement in survival of patients with oral cavity squamous cell carcinoma: An
international collaborative study. Cancer 2013;119(24):4242–8. https://doi.org/
10.1002/cncr.28357.
[9] Chinn SB, Myers JN. Oral cavity carcinoma: Current management, controversies,
and future directions. J Clin Oncol 2015;33(29):3269–76. https://doi.org/
10.1200/JCO.2015.61.2929.
[10] Sarode G, Maniyar N, Sarode SC, Jafer M, Patil S, Awan KH. Epidemiologic
aspects of oral cancer. Dis Mon 2020;66(12):100988. https://doi.org/10.1016/j.
disamonth.2020.100988.
[11] Lawrence MS, Sougnez C, Lichtenstein L, Cibulskis K, Lander E, Gabriel SB, et al.
Comprehensive genomic characterization of head and neck squamous cell
carcinomas. Nature 2015;517:576–82. https://doi.org/10.1038/nature14129.
[12] Familial Cancers of Head and Neck Region 2017:1–6. https://doi.org/10.7860/J
CDR/2017/25920.9967.
[13] Lin W, Jiang R, Wu S, Chen F, Liu S. Smoking, Alcohol, and Betel Quid and Oral
Cancer: A Prospective Cohort Study. J Oncol 2011;2011. https://doi.org/
10.1155/2011/525976.
7
Oral Oncology 121 (2021) 105451
[14] Khan Z, Tönnies J, Müller S. Smokeless tobacco and oral cancer in South Asia: A
systematic review with meta-analysis. J Cancer Epidemiol 2014;2014:1–11.
https://doi.org/10.1155/2014/394696.
[15] Siddiqi K, Husain S, Vidyasagaran A, Readshaw A, Mishu MP. Global burden of
disease due to smokeless tobacco consumption in adults: an updated analysis of
data from 127 countries. BMC Med 2020;8:222. https://doi.org/10.1186/
s12916-020-01677-9.
[16] Warnakulasuriya S, Sutherland G, Scully C. Tobacco, oral cancer, and treatment
of dependence. Oral Oncol 2005;41(3):244–60. https://doi.org/10.1016/j.
oraloncology.2004.08.010.
[17] Chen Y, Chang JT, Liao C, Wang H, Yen T, Chiu C, et al. Head and neck cancer in
the betel quid chewing area : recent advances in molecular carcinogenesis 2008;
99:1507–14. https://doi.org/10.1111/j.1349-7006.2008.00863.x.
[18] Coppe J-P, Boysen M, Sun CH, Wong BJF, Kang MK, Park N-H, et al. A role for
fibroblasts in mediating the effects of tobacco-induced epithelial cell growth and
invasion. Mol Cancer Res 2008;6(7):1085–98. https://doi.org/10.1158/1541-
7786.MCR-08-0062.
[19] Li Q, Dong H, Yang G, Song Y, Mou Y, Ni Y. Mouse Tumor-Bearing Models as
Preclinical Study Platforms for Oral Squamous Cell Carcinoma. Front Oncol 2020;
10:1–21. https://doi.org/10.3389/fonc.2020.00212.
[20] IARC Monographs on the Evaluation of Carcinogenic Risks to Humans 2010;96.
[21] Grewal P, Viswanathen VA. Liver cancer and alcohol. Clin Liver Dis 2012;16(4):
839–50. https://doi.org/10.1016/j.cld.2012.08.011.
[22] Stornetta A, Guidolin V, Balbo S. Alcohol-Derived Acetaldehyde Exposure in the
Oral Cavity. Cancers 2018;10:20. https://doi.org/10.3390/cancers10010020.
[23] Hashibe M, Brennan P, Benhamou S, Castellsague X, Chen C, Curado MP, et al.
Alcohol Drinking in Never Users of Tobacco, Cigarette Smoking in Never
Drinkers, and the Risk of Head and Neck Cancer: Pooled Analysis in the
International Head and Neck Cancer Epidemiology Consortium. JNCI 2007;99:
777–89. https://doi.org/10.1093/jnci/djk179.
[24] Kawakita D, Matsuo K. Alcohol and head and neck cancer. Cancer Metastasis Rev
2017;36(3):425–34. https://doi.org/10.1007/s10555-017-9690-0.
[25] Hübbers CU, Akgül B. HPV and cancer of the oral cavity. Virulence 2015;6(3):
244–8. https://doi.org/10.1080/21505594.2014.999570.
[26] Madhura MG, Rao RS, Patil S, Fageeh HN, Alhazmi A, Awan KH. Disease-a-Month
Advanced diagnostic aids for oral cancer. Dis Mon 2020;66(12):101034. https://
doi.org/10.1016/j.disamonth.2020.101034.
[27] Salahshourifar I, Vincent-Chong VK, Kallarakkal TG, Zain RB. Genomic DNA copy
number alterations from precursor oral lesions to oral squamous cell carcinoma.
Oral Oncol 2014;50(5):404–12. https://doi.org/10.1016/j.
oraloncology.2014.02.005.
[28] Jenkins G, O’Byrne KJ, Panizza B, Richard DJ. Genome stability pathways in head
and neck cancers. Int J Genomics 2013;2013:1–19. https://doi.org/10.1155/
2013/464720.
[29] Joo Y-H, Park S-W, Jung S-H, Lee Y-S, Nam I-C, Cho K-J, et al. Recurrent loss of
the FHIT gene and its impact on lymphatic metastasis in early oral squamous cell
carcinoma. Acta Otolaryngol 2013;133(9):992–9.
[30] Radhakrishnan R, Kabekkodu S, Satyamoorthy K. DNA hypermethylation as an
epigenetic mark for oral cancer diagnosis. J Oral Pathol Med 2011;40:665–76.
https://doi.org/10.1111/j.1600-0714.2011.01055.x.
[31] Saintigny P, Zhang Li, Fan Y-H, El-Naggar AK, Papadimitrakopoulou VA, Feng L,
et al. Gene expression profiling predicts the development of oral cancer. Cancer
Prev Res 2011;4(2):218–29. https://doi.org/10.1158/1940-6207.CAPR-10-0155.
[32] Yong ZWE, Zaini ZM, Kallarakkal TG, Karen-Ng LP, Rahman ZAA, Ismail SM,
et al. Genetic alterations of chromosome 8 genes in oral cancer. Sci Rep 2015;4
(1). https://doi.org/10.1038/srep06073.
[33] Olivier M, Hollstein M, Hainaut P. TP53 Mutations in Human Cancers: Origins,
Consequences, and Clinical Use. Cold Spring Harb Perspect Bio 2010;2:a001008.
[34] Kim S, Lee JW, Park YS. The application of next-generation sequencing to define
factors related to oral cancer and discover novel biomarkers. Life 2020;10:1–21.
https://doi.org/10.3390/life10100228.
[35] Leemans CR, Snijders PJF, Brakenhoff RH. The molecular landscape of head and
neck cancer. Nat Rev Cancer 2018;18(5):269–82. https://doi.org/10.1038/
nrc.2018.11.
[36] Alexandrov LB, Ju YS, Haase K, Van LP, et al. Mutational signatures associated
with tobacco smoking in human cance. Sci Rep 2016;354:618–22. https://doi.
org/10.1126/science.aag0299.
[37] Desrichard A, Kuo F, Chowell D, Lee K-W, Riaz N, Wong RJ, et al. Tobacco
smoking-associated alterations in the immune microenvironment of squamous
cell carcinomas. J Natl Cancer Inst 2018;110(12):1386–92. https://doi.org/
10.1093/jnci/djy060.
[38] Batta N, Pandey M. Mutational spectrum of tobacco associated oral squamous
carcinoma and its therapeutic significance. World J Surg Oncol 2019;17:1–12.
https://doi.org/10.1186/s12957-019-1741-2.
[39] Cai Yi, Yousef A, Grandis JR, Johnson DE. NSAID therapy for PIK3CA-Altered
colorectal, breast, and head and neck cancer. Adv Biol Regul 2020;75:100653.
https://doi.org/10.1016/j.jbior.2019.100653.
[40] Kozaki K-I, Imoto I, Pimkhaokham A, Hasegawa S, Tsuda H, Omura K, et al.
PIK3CA mutation is an oncogenic aberration at advanced stages of oral squamous
cell carcinoma. Cancer Sci 2006;97(12):1351–8. https://doi.org/10.1111/j.1349-
7006.2006.00343.x.
[41] Sharma V, Nandan A, Sharma AK, Singh H, Bharadwaj M, Sinha DN, et al.
Signature of genetic associations in oral cancer. 101042831772592 Tumor Biol
2017;39(10). https://doi.org/10.1177/1010428317725923.
[42] Nishikawa Y, Miyazaki T, Nakashiro KI, Yamagata H, Isokane M, Goda H, et al.
Human FAT1 Cadherin controls cell migration and invasion of oral squamous cell
A. Chamoli et al.
carcinoma through the localization of β-catenin. Oncol Rep 2011;26:587–92.
https://doi.org/10.3892/or.2011.1324.
[43] Peng Q, Deng Z, Pan H, Gu L, Liu O, Tang Z. Mitogen-activated protein kinase
signaling pathway in oral cancer. Oncol Lett 2018;15:1379–88. https://doi.org/
10.3892/ol.2017.7491.
[44] Sanzo MD, Quaresima B, Biamonte F, Palmieri C, Faniello MC. FTH1 Pseudogenes
in Cancer and Cell Metabolism. Cells 2020;9:1–17. https://dx.doi.org/10.3390%
2Fcells9122554.
[45] Ali J, Sabiha B, Jan HU, Haider SA, Khan AA, Ali SS. Genetic etiology of oral
cancer. Oral Oncol 2017;70:23–8. https://doi.org/10.1016/j.
oraloncology.2017.05.004.
[46] Gaździcka J, Gołąbek K, Strzelczyk JK, Ostrowska Z. Epigenetic Modifications in
Head and Neck Cancer. vol. 58. Springer US; 2020. https://doi.org/10.1007/s1
0528-019-09941-1.
[47] Hanahan D, Weinberg RA. Review Hallmarks of Cancer: The Next Generation.
Cell 2011;144:646–74. https://doi.org/10.1016/j.cell.2011.02.013.
[48] Costa V, Kowalski LP, Coutinho-Camillo CM, Begnami MD, Calsavara VF,
Neves JI, et al. Head and Neck Oncology EGFR amplification and expression in
oral squamous cell carcinoma in young adults. Int J Oral Maxillofac Surg 2018;47
(7):817–23. https://doi.org/10.1016/j.ijom.2018.01.002.
[49] Fujiwara T, Eguchi T, Sogawa C, Ono K, Murakami J, Ibaragi S, et al.
Carcinogenic epithelial-mesenchymal transition initiated by oral cancer exosomes
is inhibited by anti-EGFR antibody cetuximab. Oral Oncol 2018;86:251–7.
https://doi.org/10.1016/j.oraloncology.2018.09.030.
[50] Chen I-H, Chang JT, Liao C-T, Wang H-M, Hsieh L-L, Cheng A-J. Prognostic
significance of EGFR and Her-2 in oral cavity cancer in betel quid prevalent area.
Br J 2003;89(4):681–6.
[51] Yu X, Li Z, Shen J. BRD7: a novel tumor suppressor gene in different cancers. Am
J Transl Res 2016;8:742–8.
[52] Multhoff G, Molls M, Radons J, Souza AP. Chronic inflammation in cancer
development. Front Immunol 2012;2:1–17. https://doi.org/10.3389/
fimmu.2011.00098.
[53] Harjunpää H, Asens ML, Guenther C, Fagerholm SC. Cell adhesion molecules and
their roles and regulation in the immune and tumor microenvironment. Front
Immunol 2019;10:1078. https://doi.org/10.3389/fimmu.2019.01078.
[54] Göppel J, Möckelmann N, Münscher A, Sauter G, Schumacher U. Expression of
epithelial-mesenchymal transition regulating transcription factors in head and
neck squamous cell carcinomas. Anticancer Res 2017;37:5435–40. https://doi.
org/10.21873/anticanres.11971.
[55] Yanase M, Kato K, Yoshizawa K, Noguchi N, Kitahara H, Nakamura H. Prognostic
value of vascular endothelial growth factors A and C in oral squamous cell
carcinoma 2014:514–20. https://doi.org/10.1111/jop.12167.
[56] Siriwardena BSMS, Kudo Y, Ogawa I, Udagama MNGPK, Tilakaratne WM,
Takata T. VEGF-C is associated with lymphatic status and invasion in oral cancer.
J Clin Pathol 2008;61:103–8. https://doi.org/10.1136/jcp.2007.047662.
[57] Guo Y, Pan W, Liu S, Shen Z, Xu Y, Hu L. ERK/MAPK signalling pathway and
tumorigenesis(A review). Exp Ther Med 2020:1997–2007. https://doi.org/
10.3892/etm.2020.8454.
[58] Braicu C, Buse M, Busuioc C, Drula R, Gulei D, Raduly L, et al. A Comprehensive
Review on MAPK: A Promising Therapeutic Target in Cancer. Cancers 2019;11:
1618. https://doi.org/10.3390/cancers11101618.
[59] Ejaz I, Ghafoor S. WNT signalling pathway in oral lesions. J Pak Med Assoc 2019;
69:1687–92. https://doi.org/10.5455/JPMA.5890.
[60] Reyes M, Flores T, Betancur D, Peña-Oyarzún D, Torres VA. Wnt/β-catenin
signaling in oral carcinogenesis. Int J Mol Sci 2020;21:1–22. https://doi.org/
10.3390/ijms21134682.
[61] Patel S, Alam A, Pant R, Chattopadhyay S. Wnt Signaling and Its Significance
Within the Tumor Microenvironment: Novel Therapeutic Insights. Front Immunol
2019;10. https://doi.org/10.3389/fimmu.2019.02872.
[62] Huelsken J, Behrens J. The Wnt signalling pathway. J Cell Sci 2002;115:3977–8.
https://doi.org/10.1242/jcs.00089.
[63] Harsha C, Banik K, Ang HL, Girisa S, Vikkurthi R, Parama D, et al. Targeting akt/
mtor in oral cancer: Mechanisms and advances in clinical trials. Int J Mol Sci
2020;21(9):3285. https://doi.org/10.3390/ijms21093285.
[64] Fruman DA, Chiu H, Hopkins BD, Bagrodia S, Cantley LC, Abraham RT. The PI3K
Pathway in Human Disease. Cell 2017;170(4):605–35. https://doi.org/10.1016/
j.cell.2017.07.029.
[65] Wadhwa B, Makhdoomi U, Vishwakarma R, Malik F. Protein kinase B: Emerging
mechanisms of isoform-specific regulation of cellular signaling in cancer.
Anticancer Drugs 2017;28:569–80. https://doi.org/10.1097/
CAD.0000000000000496.
[66] Ferreira DM, Neves TJ, Lima LGCA, Alves FA, Begnami MD. Prognostic
implications of the phosphatidylinositol 3-kinase/Akt signaling pathway in oral
squamous cell carcinoma: overexpression of p-mTOR indicates an adverse
prognosis. Appl Cancer Res 2017;37:1–8. https://doi.org/10.1186/s41241-017-
0046-4.
[67] Liu L, Chen J, Cai X, Yao Z, Huang J. Progress in targeted therapeutic drugs for
oral squamous cell carcinoma. Surg Oncol 2019;31:90–7. https://doi.org/
10.1016/j.suronc.2019.09.001.
[68] Seoane Lestón J, Diz Dios P. Diagnostic clinical aids in oral cancer. Oral Oncol
2010;46(6):418–22. https://doi.org/10.1016/j.oraloncology.2010.03.006.
[69] Cleveland JL, Thornton-Evans G. Total diagnostic delay in oral cancer may be
related to advanced disease stage at diagnosis. J Evid Based Dent Pract 2012;12
(2):84–6. https://doi.org/10.1016/j.jebdp.2012.03.018.
[70] Walsh T, Liu JLY, Brocklehurst P, Glenny AM, Lingen M, Kerr AR, et al. Clinical
assessment to screen for the detection of oral cavity cancer and potentially
8
Oral Oncology 121 (2021) 105451
malignant disorders in apparently healthy adults. Cochrane Database Syst Rev
2013;2013. https://doi.org/10.1002/14651858.CD010173.pub2.
[71] Chuang S-L, Su W-Y, Chen S-S, Yen A-F, Wang C-P, Fann J-Y, et al. Population-
based screening program for reducing oral cancer mortality in 2,334,299
Taiwanese cigarette smokers and/or betel quid chewers. Cancer 2017;123(9):
1597–609. https://doi.org/10.1002/cncr.30517.
[72] Mascitti M, Orsini G, Tosco V, Monterubbianesi R, Balercia A, Putignano A, et al.
An overview on current non-invasive diagnostic devices in oral oncology. Front
Physiol 2018;9. https://doi.org/10.3389/fphys.2018.01510.
[73] Ernani V, Saba NF. Oral cavity cancer: Risk factors, pathology, and management.
Oncol 2015;89(4):187–95. https://doi.org/10.1159/000398801.
[74] Fitzhugh VA, Maniar KP, Gurudutt VV, Rivera M, Chen H, Wu M. Fine-Needle
Aspiration Biopsy of Granular Cell Tumor of the Tongue: A Technique for the
Aspiration of Oral Lesions. Diagn Cytopathol 2008;36:245–51. https://doi.org/
10.1002/dc.
[75] Flach GB, Tenhagen M, de Bree R, Brakenhoff RH, van der Waal I, Bloemena E,
et al. Outcome of patients with early stage oral cancer managed by an observation
strategy towards the N0 neck using ultrasound guided fine needle aspiration
cytology: No survival difference as compared to elective neck dissection. Oral
Oncol 2013;49(2):157–64. https://doi.org/10.1016/j.oraloncology.2012.08.006.
[76] Naz S, Hashmi AA, Khurshid A, Faridi N, Edhi MM, Kamal A, et al. Diagnostic role
of fine needle aspiration cytology (FNAC) in the evaluation of salivary gland
swelling: An institutional experience. BMC Res Notes 2015;8:5–9. https://doi.
org/10.1186/s13104-015-1048-5.
[77] Voskuil RT, Mayerson JL, Scharschmidt TJ. The utility of fine-needle aspiration:
how FNA has affected our musculoskeletal oncology practice. J Am Soc
Cytopathol 2020;9(6):596–601. https://doi.org/10.1016/j.jasc.2020.06.006.
[78] Ilhan B, Lin K, Guneri P, Wilder-Smith P. Improving Oral Cancer Outcomes with
Imaging and Artificial Intelligence. J Dent Res 2020;99(3):241–8. https://doi.
org/10.1177/0022034520902128.
[79] Abhyankar V, Ferrence S, Shahrabi-farahani S, Mascerenhas J, Luepke P,
Anderson KM. Biopsy Technique and Histopathological Diagnosis of Oral
Squamous Cell Carcinoma of the Tongue - A Case Report. J Dent Oral Biol 2020;5:
5–8.
[80] Mercadante V, Paderni C, Campisi G. Novel non-invasive Adjunctive Techniques
for Early Oral Cancer Diagnosis and Oral Lesions Examination. Curr Pharm Des
2012;18:5442–51. https://doi.org/10.2174/138161212803307626.
[81] Mojsa I, Kaczmarzyk T. Value of the ViziLite Plus System as a Diagnostic Aid in
the Early Detection of Oral Cancer/Premalignant Epithelial Lesions 2012;23:
162–4. https://doi.org/10.1097/SCS.0b013e31824cdbea.
[82] Böcking A, Sproll C, Stöcklein N, Naujoks C, Depprich R, Kübler NR, et al. Role of
Brush Biopsy and DNA Cytometry for Prevention, Diagnosis, Therapy, and
Followup Care of Oral Cancer. J Oncol 2011;2011:1–7. https://doi.org/10.1155/
2011/875959.
[83] Cheng YL, Rees T, Wright J. A review of research on salivary biomarkers for oral
cancer detection. Clin Transl Med 2014;3:1–10. https://doi.org/10.1186/2001-
1326-3-3.
[84] Cheng YL, Rees T, Wright J. A review of research on salivary biomarkers for oral
cancer detection. Clin Transl Med 2014;3:1–10. https://doi.org/10.1186/2001-
1326-3-3.
[85] Idris A, Ghazali NB, Koh D. Interleukin 1 β — A Potential Salivary Biomarker for
Cancer Progression ? Cancer Biomark 2015;7:25–9. https://doi.org/10.4137/BIC.
S25375.
[86] Fernandez FL, Gonzalez OR, Cedrun JLL, Lopez RL, Romay LM, Cunqueiro MMS.
Liquid biopsy in oral cancer. Int J Mol Sci 2018;19:1–15. https://doi.org/
10.3390/ijms19061704.
[87] Michailidou E, Tzimagiorgis G, Chatzopoulou F, Vahtsevanos K, Antoniadis K,
Kouidou S, et al. Salivary mRNA markers having the potential to detect oral
squamous cell carcinoma segregated from oral leukoplakia with dysplasia. Cancer
Epidemiol 2016;43:112–8. https://doi.org/10.1016/j.canep.2016.04.011.
[88] Gonzalez OR, Lopez RL, Cedrum JLL, Martinez GT, Romay LM, Cunquerio MMS.
Cell-Free microRNAs as Potential Oral Cancer Biomarkers: From Diagnosis to
Therapy. Cells 2019;8:1653.
[89] Bronkhorst AJ, Ungerer V, Holdenrieder S. The emerging role of cell-free DNA as
a molecular marker for cancer management. Biomol Detect Quantif 2019;17:
100087. https://doi.org/10.1016/j.bdq.2019.100087.
[90] Hughesman CB, Lu XJD, Liu KYP, Zhu Y, Towle RM, Haynes C, et al. Detection of
clinically relevant copy number alterations in oral cancer progression using
multiplexed droplet digital PCR. Sci Rep 2017;7:1–11. https://doi.org/10.1038/
s41598-017-11201-4.
[91] Lin L-H, Chang K-W, Kao S-Y, Cheng H-W, Liu C-J. Increased plasma circulating
cell-free DNA could be a potential marker for oral cancer. Int J Mol Sci 2018;19
(11):3303. https://doi.org/10.3390/ijms19113303.
[92] Morikawa T, Shibahara T, Nomura T, Katakura A, Takano M. Non-Invasive Early
Detection of Oral Cancers Using Fluorescence Visualization with Optical
Instruments. Cancers(Basel) 2020;12(10):2771. https://doi.org/10.3390/
cancers12102771.
[93] McNamara KK, Martin BD, Evans EW, Kalmar JR. The role of direct visual
fluorescent examination (VELscope) in routine screening for potentially
malignant oral mucosal lesions. J Oral Maxillofac Pathol 2012;114(5):636–43.
https://doi.org/10.1016/j.oooo.2012.07.484.
[94] Basu S, Hess S, Braad PN. The Basic Principles of FDG-PET/CT Imaging. PET Clin
2014;9:355–70. https://doi.org/10.1016/j.cpet.2014.07.006.
[95] Wu J, Yuan Y, Tao X. Targeted molecular imaging of head and neck squamous cell
carcinoma: window into precision medicine. Chin Med J 2020;133:1325–36.
https://doi.org/10.1097/CM9.0000000000000751.
A. Chamoli et al.
[96] Li L, Zhou S, Zhao K, Wang S, Wu Q, Fan J, et al. Clinical Significance of FDG
Single-Photon Emission Computed Tomography: Computed Tomography in the
Diagnosis of Head and Neck Cancers and Study of Its Mechanism. Cancer Biother
Radiophrm 2008;23:701–14. https://doi.org/10.1089/cbr.2008.0510.
[97] Hong HR, Jin S, Koo HJ, Roh J-L, Kim JS, Cho K-J, et al. Clinical Values of 18 F-
FDG PET/CT in Oral Cavity Cancer with Dental Artifacts on CT or MRI. J Surg
Oncol 2014;110(6):696–701. https://doi.org/10.1002/jso.23691.
[98] Zheng D, Niu L, Fei J, Li K, Tian J. F-FDG PET/CT in diagnosis and staging of
tongue squamous cell carcinoma. Int J Clin Exp Med 2019;12:735–43.
[99] Pasha MA, Marcus C, Fakhry C, Kang H, Kiess AP, Subramaniam RM. FDG PET/
CT for management and assessing outcomes of squamous cell cancer of the oral
cavity. Am J Roentgenol 2015;205(2):W150–61. https://doi.org/10.2214/
AJR.14.13830.
[100] Drage N, Qureshi S, Lingam R. Imaging patients with cancer of the oral cavity. Br
Dent J 2018;225(9):827–32. https://doi.org/10.1038/sj.bdj.2018.929.
[101] Kao C-H, Hsieh T-C, Yu C-Y, Yen K-Y, Yang S-N, Wang Y-C, et al. 18F-FDG PET/
CT-based gross tumor volume definition for radiotherapy in head and neck
Cancer: A correlation study between suitable uptake value threshold and tumor
parameters. Radiat Oncol 2010;5(1):76. https://doi.org/10.1186/1748-717X-5-
76.
[102] Bae MR, Roh J-L, Kim JS, Lee JH, Cho K-J, Choi S-H, et al. 18F-FDG PET/CT
versus CT/MR imaging for detection of neck lymph node metastasis in palpably
node-negative oral cavity cancer. J Cancer Res Clin Oncol 2020;146(1):237–44.
https://doi.org/10.1007/s00432-019-03054-3.
[103] Er T-K, Wang Y-Y, Chen C-C, Herreros-Villanueva M, Liu T-C, Yuan S-S. Molecular
characterization of oral squamous cell carcinoma using targeted next-generation
sequencing. Oral Dis 2015;21(7):872–8. https://doi.org/10.1111/odi.12357.
[104] Lydiatt WM, Patel SG, O’Sullivan B, Brandwein MS, Ridge JA, Migliacci JC, et al.
Head and neck cancers-major changes in the American Joint Committee on cancer
eighth edition cancer staging manual. CA Cancer J Clin 2017;67:122–37. https://
doi.org/10.3322/caac.21389.
[105] Ettinger KS, Ganry L, Fernandes RP. Oral Cavity Cancer. Oral Maxillofac Surg Clin
NA 2019;31(1):13–29. https://doi.org/10.1016/j.coms.2018.08.002.
[106] AJCC - AJCC 8th Edition Cancer Staging Form, Histology and Topography
Supplements https://cancerstaging.org/About/news/Pages/AJCC-8th-Edition-
Cancer-Staging-Form-and-Histology-and-Topography-Supplements-Available-No
w.aspx (accessed June 29, 2021).
[107] AJCC - 8th Edition Updates and Corrections. https://cancerstaging.org/reference
s-tools/deskreferences/pages/8eupdates.aspx (accessed June 29, 2021).
[108] Zaigham A, Rehman S. IntechOpen. An Overv Cancer Treat Modalities Chapter
2018:141. https://doi.org/10.1016/j.colsurfa.2011.12.014.
Oral Oncology 121 (2021) 105451
[109] Schomberg J. Identification of Targetable Pathways in Oral Cancer Patients via
Random Forest and Chemical Informatics. Cancer Inform 2019;18:1–12. https://
doi.org/10.1177/1176935119889911.
[110] Hartner L. Chemotherapy for Oral Cancer. Dent Clin North Am 2018;62(1):87–97.
https://doi.org/10.1016/j.cden.2017.08.006.
[111] Shrime MG, Gullane PJ, Dawson L, Kim J, Gilbert RW, Irish JC, et al. The Impact
of Adjuvant Radiotherapy on Survivalin T1–2N1 Squamous Cell Carcinoma of the
Oral Cavity. Arch Otolaryngol Head Neck Surg 2010;136(3):225. https://doi.org/
10.1001/archoto.2010.22.
[112] Huang S, Sullivan BO. Oral cancer: Current role of radiotherapy and
chemotherapy 2013;18:e233–40. https://doi.org/10.4317/medoral.18772.
[113] Nichols AC, Yoo J, Hammond JA, Fung K, Winquist E, Read N, et al. Early-stage
squamous cell carcinoma of the oropharynx: Radiotherapy vs. Trans-Oral Robotic
Surgery (ORATOR) – study protocol for a randomized phase II trial. BMC Cancer
2013;13(133).
[114] Dine J, Gordon R, Shames Y, Kasler MK, Barton-burke M. Immune Checkpoint
Inhibitors: An Innovation in Immunotherapy for the Treatment and Management
of Patients with Cancer of immunotherapies reflects a promising new approach to
cancer treatment involving activation of the immune system against cancer.
Immune Asia Pac J Oncol Nurs 2017;4:127–35. https://doi.org/10.4103/apjon.
apjon.
[115] Arruebo M, Vilaboa N, Sáez-Gutierrez B, Lambea J, Tres A, Valladares Mónica,
et al. Assessment of the evolution of cancer treatment therapies. Cancers (Basel)
2011;3(3):3279–330. https://doi.org/10.3390/cancers3033279.
[116] Ries J, Agaimy A, Wehrhan F, Baran C, Bolze S, Danzer E, et al. Importance of the
PD-1/PD-L1 Axis for Malignant Transformation and Risk Assessment of Oral
Leukoplakia 2021:1–25.
[117] Schoenfeld JD, Hanna GJ, Jo VY, Rawal B, Chen Y-H, Catalano PS, et al.
Neoadjuvant Nivolumab or Nivolumab plus Ipilimumab in Untreated Oral Cavity
Squamous Cell Carcinoma: A Phase 2 Open-Label Randomized Clinical Trial.
JAMA Oncol 2020;6(10):1563. https://doi.org/10.1001/jamaoncol.2020.2955.
[118] Abrahao AC, Castilho RM, Squarize CH, Molinolo AA, Santos-Pinto Ddos,
Gutkind JS. A role for COX2-derived PGE2 and PGE2-receptor subtypes in head
and neck squamous carcinoma cell proliferation. Oral Oncol 2010;46(12):880–7.
https://doi.org/10.1016/j.oraloncology.2010.09.005.
[119] De Oliveira M, Novaes JA, William WN. Prognostic factors, predictive markers
and cancer biology: The triad for successful oral cancer chemoprevention. Futur.
Oncol 2016;12:2379–86. https://doi.org/10.2217/fon-2016-0168.
[120] Saini R, Lee NV, Liu KYP, Poh CF. Prospects in the application of photodynamic
therapy in oral cancer and premalignant lesions. Cancers (Basel) 2016;8:1–14.
https://doi.org/10.3390/cancers8090083.