ONLINE ONLY ARTICLES - ORIGINAL ARTICLE
|Year : 2019 | Volume
| Issue : 2 | Page : 301
Expression of cyclooxygenase 2 in oral submucous fibrosis: An immunohistochemical pilot study
Shruthi Rangaswamy1, Rajkumar Garudanahally Chikkalingaiah2, P Sharada3, Vinod K Kumar3
1 Department of Oral and Maxillofacial Surgery, Rajarajeshwari Dental College and Hospital, Bengaluru, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, V. S. Dental College and Hospital, Bengaluru, Karnataka, India
3 Department of Oral and Maxillofacial Pathology, AECS Maaruti College of Dental Sciences and Research Center, Bengaluru, Karnataka, India
|Date of Submission||26-Oct-2018|
|Date of Acceptance||08-Dec-2018|
|Date of Web Publication||20-Aug-2019|
Rajarajeshwari Dental College and Hospital, Ramohalli Cross, Mysore Road, Bengaluru - 560 056, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Oral submucous fibrosis (OSF) is associated with inflammatory changes in at least some stages of the disease. Prostaglandin is one of the main inflammatory mediators and its production is controlled by various enzymes such as cyclooxygenase (COX). The genetic and pharmacological data strongly indicate that COX-2 should be investigated as a potential target for the prevention and treatment of OSF.
Methodology: The study group comprised histologically confirmed specimens (n = 10 each) of early OSF, moderate OSF, advanced OSF and normal oral mucosa for comparison. Immunohistochemistry was performed with avidin–biotin technique and evaluated with scoring methods.
Results: The difference in percentage of expression in normal tissue and OSF was statistically highly significant (P < 0.001). Positive COX-2 exhibited cytoplasmic staining. One-way analysis of variances test was performed to evaluate COX-2 expression in different grades of OSF. Cytoplasmic staining assessed in terms of intensity, percentage of expression and Q Score did not show any statistical difference (percentage of expression F = 0.029, P = 0.971; Q Score F = 0.154, P = 0.858).
Conclusions: Our study indicates that COX-2 may be an important marker of disease progression and might be a reliable prognostic indicator.
Keywords: Cyclooxygenase-2, immunohistochemistry, oral submucous fibrosis, salivary expression
|How to cite this article:|
Rangaswamy S, Chikkalingaiah RG, Sharada P, Kumar VK. Expression of cyclooxygenase 2 in oral submucous fibrosis: An immunohistochemical pilot study. J Oral Maxillofac Pathol 2019;23:301
|How to cite this URL:|
Rangaswamy S, Chikkalingaiah RG, Sharada P, Kumar VK. Expression of cyclooxygenase 2 in oral submucous fibrosis: An immunohistochemical pilot study. J Oral Maxillofac Pathol [serial online] 2019 [cited 2020 Jan 25];23:301. Available from: http://www.jomfp.in/text.asp?2019/23/2/301/264807
| Introduction|| |
Oral submucous fibrosis (OSF) is chronic, progressive, precancerous condition with high chance of malignant transformation. Numerous biological pathways are involved in pathogenesis of submucous fibrosis and its transition to cancer. Precise molecular mechanisms deserve exploration. Inflammation is observed in some stage of OSF and may have a role in disease progression and malignant transformation.
Prostaglandin-endoperoxide synthase, commonly called as cyclooxygenase (COX), is the key regulatory enzyme in tissue inflammation and is present in two isoforms COX-1 and COX-2. COX-2 is an inducible form of COX, and its overexpression has been shown to promote tumorigenesis by activation of carcinogens, cytokines, neoangiogenesis, stimulating progression and inhibiting apoptosis. Researchers have found that molecular changes in oral premalignant condition are preceded by alteration in COX gene expression.
Upregulation of COX-2 has been shown in oral potentially malignant lesions and oral squamous cell carcinoma.,,,, It can be a prognostic predictor and molecular target, thus it needs to be evaluated. The aim of the study was to assess the immunohistochemical expression of COX-2 enzyme in normal mucosa and submucous fibrosis and further deliberate difference in histological grades of submucous fibrosis.
| Methodology|| |
Formalin-fixed, paraffin-embedded OSF tissue blocks were obtained from departmental archives. 5-μm sections of samples were stained with routine hematoxylin and eosin and analyzed under light microscopy. The stained sections were analyzed by three oral pathologists without prior knowledge of clinical data to histologically grade the submucous fibrosis and dysplasia according to the WHO 2005, In the cases of disagreement, the pathologists discussed the findings and performed the final evaluation. Ten samples of early OSF (EOSF), moderate OSF (MOSF) and advanced OSF (AOSF) each were randomly selected. Ten samples of normal mucosa were processed.
Immunohistochemistry (IHC) was performed with avidin–biotin technique and the 5-μm sections were placed on positively charged slides. Sections were deparaffinized, rehydrated and quenched. IHC staining was done with commercially prepared antibodies for COX-2 in Autostainer Intelipath (monoclonal antibodies from mice, MACH 1 Mouse Probe, Biocare medicals USA). Antigen retrieval was done using ethylenediamminetetraacetate solution with pH 8 sections were covered with Mach 1 HP Polymer incubated with secondary antibody. Antigen-antibody binding was detected with Betazoid DAB Chromogen and sections were counterstained with CAT hematoxylin counterstain. Expression of the marker was evaluated using scoring methods [Table 1] and [Table 2].
The data obtained from the proteins expression were submitted for analysis of variance (ANOVA) to assess the statistical difference in percentage of expression and Q Score between the groups. Independent Student's t-test was applied to compare normal and submucous fibrosis groups. Chi-square test was applied to evaluate the degree of dysplasia in different grades and different expression.
| Results|| |
COX-2 immunoexpression was done using standard immunohistochemical techniques. The study group comprised histologically confirmed specimens (n = 10 each) of EOSF, MOSF, AOSF and normal oral mucosa for comparison.
COX-2 was not expressed in morphologically normal mucosa [Figure 1]; out of 10 cases, 6 cases did not show any uptake, 3 cases showed 25% low-intensity expression and 1 case showed 50% low-intensity expression (mean: 17.5% of expression). The difference in percentage of expression in normal tissue and OSF was statistically highly significant (P < 0.001). Comparison of Q Score of normal and OSF tissue showed statistical difference in two groups (N mean = 25, standard deviation [SD] = 33.33; OSF mean = 138.33, SD = 90.195 P < 0.001). COX-2 protein found to be expressed in increasing intensity in OSF compared to normal mucosa [Graph 1].
|Figure 1: Complete absence of immunohistochemistry expression of cyclooxygenase-2 in normal mucosa|
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Quantitative scoring methods
One-way ANOVA test was performed to evaluate COX-2 expression in different grades of OSF. Cytoplasmic staining assessed in terms of intensity, percentage of expression and Q Score did not show any statistical difference (percentage of expression F = 0.029, P = 0.971 [Table 3]; Q Score F = 0.154, P = 0.858). EOSF group showed 100% expression in 4 cases, MOSF in 3 cases and AOSF in 4 cases. Stronger intensity was found in EOSF [Graph 2]. However, strong immunostaining was observed in EOSF and MOSF [Figure 2] compared to AOSF even though the difference is statistically not significant (Q Score: EOSF and MOSF mean = 145 and AOSF mean = 125) [Graph 3].,,
|Figure 2: A diffuse dense cytoplasmic expression of cyclooxygenase-2 in basal parabasal and intermediate cells of epithelium associated with oral submucous fibrosis|
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Increased uptake was observed with increased dysplasia, suggesting that increased COX-2 may contribute to malignant change in OSF cases (P = 0.028). Since only one case of severe dysplasia was seen, this aspect needs to be further evaluated with larger sample.
In samples showing 100% epithelial uptake, six cases showed moderate dysplasia and one case of severe dysplasia suggesting COX-2 is associated with dysplasia [Figure 3], whereas in cases <25% (n = 4) uptake showed no dysplasia in two cases mild dysplasia in two cases. The difference is not statistically significant when correlated. There is no statistical difference in degree of dysplasia between different grades of OSF.
|Figure 3: Dense diffuse cytoplasmic and membranous expression of cyclooxygenase-2 in dysplastic cells in entire thickness of the epithelium|
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Fifteen samples out of 30 samples have taken up COX-2 staining which accounts for 50%. No statistical difference was found between OSF grades with respect to connective tissue uptake of COX-2. However, with increase in percentage of expression in epithelium, increased connective tissue expression is observed [Graph 4].
Interestingly, 7 out of 30 cases showed intense uptake by minor salivary gland [Figure 4] and such expression was not seen in the normal mucosa. Ductal epithelium was taking more stain compared to acinic cells.
|Figure 4: Immunohistochemistry expression of cyclooxygenase-2 in complete thickness of epithelium and minor salivary gland|
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| Discussion|| |
COX-2 is an inducible isoform of cyclooxygenase derived from arachidonic acid that plays an important role in various pathophysiologic conditions. COX-2 is normally not detectable in tissue but induced by trauma, pro-inflammatory or mitogenic stimuli., COX-2 has been paid attention since it could play an important role in the initiation and progression of carcinomas of the various organs.,,, Upregulation of COX-2 is associated with increased angiogenesis, proliferation of cancer stem cells and inhibition of apoptosis.
Tissue inflammation is believed to play an important role in occurrence of tissue fibrosis. OSF and lichen planus are potentially malignant disorders where immunoinflammatory processes are implicated in pathogenesis and malignant transformation. Very few studies have been done to evaluate the COX-2 expression in OSF. Tsai et al. demonstrated that COX-2 was significantly higher in OSF specimens and expressed mainly in epithelial cells, endothelial cells and fibroblasts. They also observed that COX-2 expression in cells treated with arecoline was upregulated as early as half an hour, suggesting that COX-2 is an early cellular response. Studies have shown 1.4–3.4-fold increase of PGE2 production and 1.1–1.7-fold increase of PGE 1 when gingival keratinocytes exposed to areca nut extracts.,
The present study was done to record the immunohistochemical expression of COX-2 in normal oral mucosa and different grades of submucous fibrosis. Increased uptake of COX was seen in OSF specimens compared to normal mucosa. Our result is similar to those obtained in the previous studies that found an increased COX-2 expression from normal to oral potentially malignant disorders to OSCC, but it is especially in accordance to the results obtained by Shibata et al., who evaluated the expression of COX-1 and COX-2 in oral carcinogenesis and found that COX-2 expression was higher in oral dysplasia than in OSCC. COX (COX-2) expression analysis by Singh et al. Immunocytochemistry and Western blot found synchronization in both the assays which support the finding that COX-2 expression is upregulated in OSF specimens compared to normal oral submucosal cells. Strong immunostaining for COX-2 was detected in arecoline exposed normal oral mucosal cells and in OSF samples.
Immunoreactivity for COX-2 was mainly found in the cytoplasmic compartment. COX-2 uptake was limited to suprabasal layers in EOSF and connective tissue uptake was seen in advanced cases with dysplastic changes although the difference could not be statistically proved. COX-2 was cytoplasmic in cancer cells, and it was also observed in the stromal components, especially in inflammatory cells, suggesting that the immunoreactivity for COX-2 may be modulated by interaction of the stromal cells with cancer cells in the process of destructive invasion. Cytoplasmic staining was also assessed in terms of the intensity of the immunopositive reaction. No statistical difference was found among the groups. Similar immunoreactivity has been reported by Itoh in oral squamous cell carcinoma.
Statistically, we could not find a correlation between the COX-2 overexpression and histological grades of submucous fibrosis. Strong immunostaining was observed in EOSF and MOSF compared to AOSF comparable to a study by Gallo et al. where biopsies from buccal mucosa of OSF cases and controls were stained for COX-2 by IHC and revealed that there was increased expression of the enzyme in moderate fibrosis, and this disappeared in advanced fibrosis. This finding is compatible with the histology of the disease, as there is a lack of inflammation in the advanced disease.
OSF is characterized by the formation of thick bands of collagen fibers and hyalinization extending deep into the submucosal tissues and decreased vascularity. Inflammation and fibrosis of minor salivary glands and muscle degeneration will occur in advanced stages of OSF. On histological examination, varying degree of fibrosis of minor salivary gland has been observed with degenerative change in mucous acini., We observed increased uptake of immunostaining by the minor salivary glands in OSF group, suggesting alteration in salivary secretions may be part of pathogenesis COX-2 immunoreactivity might be modulated by the interaction of stromal cells and cancer cells during progression to advanced disease or invasion. In vivo autofluorescence from the buccal mucosa seems to be an interesting noninvasive tool to differentiate normal mucosa from OSF and early carcinoma.
Nevertheless, due to the small number of samples included in this study, general statements regarding correlation between the degree of severity of the OSF pathology and the quantitative expression of these potential markers cannot be made. Prospective studies with larger samples may be of greater clinical importance and reliable prognostic indicator.
| Conclusions|| |
Our findings regarding COX-2 expression suggest that as OSF progresses the population of epithelial cells immunoreactive for COX-2 also increases. This indicates that COX-2 may be an important marker of disease progression. Current failure in treatment of submucous fibrosis is due to our inability to target molecular mechanisms. COX-2 can serve as predictor toward disease progression and malignant transformation. Further studies on this can help in early intervention with COX inhibitors or immune modulators for the benefit for the humankind.
The authors would like to thank Dr. Girish H. C., professor, Rajarajeshwari Dental College, for their contribution in processing sample.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jeng JH, Chang MC, Hahn LJ. Role of areca nut in betel quid-associated chemical carcinogenesis: Current awareness and future perspectives. Oral Oncol 2001;37:477-92.
Sawhney M, Rohatgi N, Kaur J, Shishodia S, Sethi G, Gupta SD, et al.
Expression of NF-kappaB parallels COX-2 expression in oral precancer and cancer: Association with smokeless tobacco. Int J Cancer 2007;120:2545-56.
Banerjee AG, Gopalakrishnan VK, Bhattacharya I, Vishwanatha JK. Deregulated cyclooxygenase-2 expression in oral premalignant tissues. Mol Cancer Ther 2002;1:1265-71.
Zhang S, Du Y, Tao J, Wu Y, Chen N. Expression of cytosolic phospholipase A2 and cyclooxygenase 2 and their significance in human oral mucosae, dysplasias and squamous cell carcinomas. ORL J Otorhinolaryngol Relat Spec 2008;70:242-8.
Sun XJ, Ma J, Zhang H, Wang XK, Li JH. The expressions of cyclooxygenase-2 (Cox-2), VEGF in oral squamous cell carcinoma and precancerous lesions and their significances. Shanghai Kou Qiang Yi Xue 2005;14:173-6.
Chan G, Boyle JO, Yang EK, Zhang F, Sacks PG, Shah JP, et al.
Cyclooxygenase-2 expression is up-regulated in squamous cell carcinoma of the head and neck. Cancer Res 1999;59:991-4.
Shibata M, Kodani I, Osaki M, Araki K, Adachi H, Ryoke K, et al.
Cyclo-oxygenase-1 and -2 expression in human oral mucosa, dysplasias and squamous cell carcinomas and their pathological significance. Oral Oncol 2005;41:304-12.
Sudbø J, Ristimäki A, Sondresen JE, Kildal W, Boysen M, Koppang HS, et al.
Cyclooxygenase-2 (COX-2) expression in high-risk premalignant oral lesions. Oral Oncol 2003;39:497-505.
Barnes L, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization Classification of Tumours. Pathology and Genetics. Head and Neck Tumours. International Agency for Research on Cancer (IARC). Head and Neck Tumors. Lyon: IARC Press; 2005. p. 177-80.
Warnakulasuriya S, Reibel J, Bouquot J, Dabelsteen E. Oral epithelial dysplasia classification systems: Predictive value, utility, weaknesses and scope for improvement. J Oral Pathol Med 2008;37:127-33.
McDonald JW, Pilgram TK. Nuclear expression of p53, p21 and cyclin D1 is increased in bronchioloalveolar carcinoma. Histopathology 1999;34:439-46.
Shiao YH, Palli D, Caporaso NE, Alvord WG, Amorosi A, Nesi G, et al.
Genetic and immunohistochemical analyses of p53 independently predict regional metastasis of gastric cancers. Cancer Epidemiol Biomarkers Prev 2000;9:631-3.
Charafe-Jauffret E, Tarpin C, Bardou VJ, Bertucci F, Ginestier C, Braud AC, et al.
Immunophenotypic analysis of inflammatory breast cancers: Identification of an 'inflammatory signature'. J Pathol 2004;202:265-73.
Vane JR, Mitchell JA, Appleton I, Tomlinson A, Bishop-Bailey D, Croxtall J, et al.
Inducible isoforms of cyclooxygenase and nitric-oxide synthase in inflammation. Proc Natl Acad Sci U S A 1994;91:2046-50.
Kargman S, Charleson S, Cartwright M, Frank J, Riendeau D, Mancini J, et al.
Characterization of prostaglandin G/H synthase 1 and 2 in rat, dog, monkey, and human gastrointestinal tracts. Gastroenterology 1996;111:445-54.
Sano H, Kawahito Y, Wilder RL, Hashiramoto A, Mukai S, Asai K, et al.
Expression of cyclooxygenase-1 and -2 in human colorectal cancer. Cancer Res 1995;55:3785-9.
Snyderman CH, Milanovich M, Wagner RL, Johnson JT. Prognostic significance of prostaglandin E2 production in fresh tissues of head and neck cancer patients. Head Neck 1995;17:108-13.
Costa C, Soares R, Reis-Filho JS, Leitão D, Amendoeira I, Schmitt FC, et al.
Cyclo-oxygenase 2 expression is associated with angiogenesis and lymph node metastasis in human breast cancer. J Clin Pathol 2002;55:429-34.
Tsujii M, DuBois RN. Alterations in cellular adhesion and apoptosis in epithelial cells overexpressing prostaglandin endoperoxide synthase 2. Cell 1995;83:493-501.
Tsai CH, Chou MY, Chang YC. The up-regulation of cyclooxygenase-2 expression in human buccal mucosal fibroblasts by arecoline: A possible role in the pathogenesis of oral submucous fibrosis. J Oral Pathol Med 2003;32:146-53.
Jeng JH, Ho YS, Chan CP, Wang YJ, Hahn LJ, Lei D, et al.
Areca nut extract up-regulates prostaglandin production, cyclooxygenase-2 mRNA and protein expression of human oral keratinocytes. Carcinogenesis 2000;21:1365-70.
Byatnal AA, Byatnal A, Sen S, Guddattu V, Solomon MC. Cyclooxygenase-2 – An imperative prognostic biomarker in oral squamous cell carcinoma – An immunohistochemical study. Pathol Oncol Res 2015;21:1123-31.
Singh V, Mohammad S, Pant AP, Saimbi CS, Srivastava R. Therapeutic interventions in oral submucous fibrosis: An experimental and clinical study. J Maxillofac Oral Surg 2015;14:278-90.
Itoh S, Matsui K, Furuta I, Takano Y. Immunohistochemical study on overexpression of cyclooxygenase-2 in squamous cell carcinoma of the oral cavity: Its importance as a prognostic predictor. Oral Oncol 2003;39:829-35.
Gallo O, Masini E, Bianchi B, Bruschini L, Paglierani M, Franchi A. Prognostic significance of cyclooxygenase-2 pathway and angiogenesis in head and neck squamous cell carcinoma. Hum Pathol 2002;33:708-14.
Shafique K, Mirza SS, Vart P, Memon AR, Arain MI, Tareen MF, et al.
Areca nut chewing and systemic inflammation: Evidence of a common pathway for systemic diseases. J Inflamm (Lond) 2012;9:22.
Sarode SC, Sarode GS. Burning sensation in oral submucous fibrosis and its possible association with mucin secreted by affected minor salivary glands. Oral Oncol 2013;49:e16-7.
Auluck A, Hislop G, Poh C, Zhang L, Rosin MP. Areca nut and betel quid chewing among South Asian immigrants to western countries and its implications for oral cancer screening. Rural Remote Health 2009;9:1118.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]