Association of Serum and Salivary Tumor Necrosis Factor-α with Histological Grading in Oral Cancer and its Role in Differentiating Premalignant and Malignant Oral Disease

  • Krishnan, Rajkumar (Department of Oral and Maxillofacial Pathology, SRM Dental College, SRM University) ;
  • Thayalan, Dinesh Kumar (Department of Oral and Maxillofacial Pathology, SRM Dental College, SRM University) ;
  • Padmanaban, Rajashree (Department of Oral and Maxillofacial Pathology, SRM Dental College, SRM University) ;
  • Ramadas, Ramya (Department of Oral and Maxillofacial Pathology, SRM Dental College, SRM University) ;
  • Annasamy, Ramesh Kumar (Department of Oral and Maxillofacial Pathology, SRM Dental College, SRM University) ;
  • Anandan, Nirmala (Department of Biochemistry, SRM Dental College, SRM University)
  • Published : 2014.09.15


Background: Oral squamous cell carcinoma (OSCC) is an important malignancy throughout the world; early detection is an important criterion for achieving high cure rate. Out of the many reported markers for OSCC, this study validated the efficacy of tumor necrosis factor-${\alpha}$ (TNF-${\alpha}$) in differentially diagnosing premalignant oral lesions and OSCC. Also, the study aimed to correlate the levels of salivary and serum TNF-${\alpha}$ with clinicopathologic factors. Materials and Methods: A prospective experimental laboratory study was designed. Serum and salivary samples from 100 subjects in each group of healthy control, premalignant disease (PMD) and OSCC were collected for the study following appropriate exclusion and inclusion criteria. Serum and salivary level of TNF-${\alpha}$ was analysed by enzyme linked immunosorbent assay. The data obtained were subjected to appropriate statistical analysis. Results: Increased level of both serum and salivary TNF-${\alpha}$ was observed in OSCC subjects compared to healthy control and PMD group. Receiver operator characteristic curve analysis and area under curve values showed high specificity and sensitivity for salivary TNF-${\alpha}$ in differentiating OSCC from PMD and healthy controls. There was significant increase in TNF-${\alpha}$ level in moderately and poorly differentiated lesion compared to well differentiated lesion and in stage IV of clinical stage. A positive correlation was observed only with histological grading of OSCC and TNF-${\alpha}$. Conclusions: Salivary TNF-${\alpha}$ is proved to be superior for detecting OSCC. Increase in TNF-${\alpha}$ with histological grading and clinical staging suggests a role in prognosis.


  1. Anneroth G, Batsakis J, Luna M (1987). Review of the literature and a recommended system of malignancy grading in oral squamous cell carcinomas. Scandinavian J Dental Res, 95, 229-9.
  2. Arnott CH, Scott KA, Moore RJ, et al (2002). Tumour necrosis factor-alpha mediates tumour promotion via a PKC alphaand AP-1-dependent pathway. Oncogene, 21, 4728-8.
  3. Brailo V, Vucicevic-Boras V, Cekic-Arambasin A, etal (2006). The significance of salivary interleukin 6 and tumor necrosis factor alpha in patients with oral leukoplakia. Oral Oncol, 42, 370-3.
  4. Brailo V, Vucicevic-Boras V, Lukac J, Biocina-Lukenda D, et al (2012). Salivary and serum interleukin 1 beta, interleukin 6 and tumor necrosis factor alpha in patients with leukoplakia and oral cancer. Medicina Oral, Patologia Oral Y Cirugia Bucal, 17, 10-5.
  5. Brocklehurst P, Kujan O, Glenny AM, et al (2010). Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev, 11, 1-27.
  6. Chen F-C, Zhang F, Zhang Z-J, et al (2013). Tumor necrosis factor-$\alpha$ gene polymorphisms and risk of oral cancer: evidence from a meta-analysis. Asian Pac J Cancer Prev, 14, 7243-9.
  7. Cheng K, Zhao YJ, Liu L, Wan JJ (2013). Tumor necrosis factor-$\alpha$ 238 G/A polymorphism and risk of hepatocellular carcinoma: evidence from a meta-analysis. Asian Pac J Cancer Prev, 14, 3275-9.
  8. Curnis F, Sacchi A, Corti A (2002). Improving chemotherapeutic drug penetration in tumors by vascular targeting and barrier alteration. J Clin Investigation, 110, 475-82.
  9. Daniel D, Wilson NS (2008). Tumor necrosis factor: renaissance as a cancer therapeutic? Current Cancer Drug Targets, 8, 124-31.
  10. Dobrzycka B, Terlikowski SJ, Kowalczuk O, Kinalski M (2009). Circulating levels of TNF-alpha and its soluble receptors in the plasma of patients with epithelial ovarian cancer. European cytokine network, 20, 131-4.
  11. Fang-Chun C, Zhang F, Zhi-Jiao Z et al (2013). Tumor necrosis factor-$\alpha$ gene polymorphisms and risk of oral cancer: evidence from a meta-analysis. Asian Pac J Cancer Prev, 14, 7243-9.
  12. Fang L, Lin S, Fang-Fang H, Qiao-Er C (2013). Effects of fasl expression in oral squamous cell cancer. Asian Pac J Cancer Prev, 14, 281-5.
  13. Fuksiewicz M, Kowalska M, Kotowicz B, et al (2010). Serum soluble tumour necrosis factor receptor type I concentrations independently predict prognosis in patients with breast cancer. Clinical chemistry and laboratory medicine: CCLM/FESCC, 48, 1481-6.
  14. Hohberger L, Wuertz BR, Xie H, Griffin T, Ondrey F (2008). TNF-alpha drives matrix metalloproteinase-9 in squamous oral carcinogenesis. The Laryngoscope, 118, 1395-9.
  15. Hsiao SH, Lee MS, Lin HY, et al (2009). Clinical significance of measuring levels of tumor necrosis factor-alpha and soluble interleukin-2 receptor in nasopharyngeal carcinoma. Acta oto-laryngologica, 129, 1519-3.
  16. Il'yasova D, Colbert LH, Harris TB, et al (2005). Circulating levels of inflammatory markers and cancer risk in the health aging and body composition cohort. Cancer Epidemiol Biomarkers Prev, 14, 2413-8.
  17. Jablonska E, Kiluk M, Markiewicz W, et al (2001). TNF-alpha, IL-6 and their soluble receptor serum levels and secretion by neutrophils in cancer patients. Arch Immunol Ther Exp, 49, 63-9.
  18. Jablonska E, Kiluk M, Piotrowski L, et al (1998). Tumor necrosis factor-alpha and soluble tumor necrosis factor receptors in the culture supernatants of polymorphonuclear cells and peripheral blood mononuclear cells from cancer patients. Eur Cytokine Betwork, 9, 155-9.
  19. Jablonska E, Piotrowski L, Grabowska Z (1997). Serum Levels of IL-1b, IL-6, TNF-a, sTNF-RI and CRP in Patients with Oral Cavity Cancer. Pathology Oncol Res, POR, 3, 126-9.
  20. Johnson NW, Warnakulasuriya S, Gupta PC, et al (2011). Global oral health inequalities in incidence and outcomes for oral cancer: causes and solutions. Adv Dental Res, 23, 237-6.
  21. Juretic M, Cerovic R, Belusic-Gobic M, Brekalo Prso I, Kqiku L, Spalj S, et al (2013). Salivary levels of TNF-alpha and IL-6 in patients with oral premalignant and malignant lesions. Folia Biologica, 59, 99-102.
  22. Komori A, Yatsunami J, Suganuma M, et al (1993). Tumor necrosis factor acts as a tumor promoter in BALB/3T3 cell transformation. Cancer Res, 53, 1982-5.
  23. Kotowicz B, Kaminska J, Fuksiewicz M, et al (2010). Clinical significance of serum CA-125 and soluble tumor necrosis factor receptor type I in cervical adenocarcinoma patients. Int J Gynecol Cancer, 20, 588-92.
  24. Krishna Prasad RB, Sharma A, Babu HM (2013). An insight into salivary markers in oral cancer. Dental Res J, 10, 287-95.
  25. Kurokawa H, Yamashita M, Yamashita Y, Murata T, Miura K, Kajiyama M (1998). Estimation of tumor necrosis factoralpha in the diagnosis, the prognosis and the treatment follow-up of oral squamous cell carcinoma. Fukuoka Igaku Zasshi, 89, 312-20.
  26. Lee SH, Hong HS, Liu ZX, et al (2012). TNFalpha enhances cancer stem cell-like phenotype via Notch-Hes1 activation in oral squamous cell carcinoma cells. Biochem Biophys Res Commun, 424, 58-64.
  27. Marzieh H, Azadeh AT, Gita R, et al (2013). Tissue expression, serum and salivary levels of IL-10 in patients with head and neck squamous cell carcinoma. Asian Pac J Cancer Prev, 14, 1681-5.
  28. Mehrotra R, Gupta DK (2011). Exciting new advances in oral cancer diagnosis: avenues to early detection. Head and Neck Oncol, 3, 33.
  29. Morrison MD, Reiley W, Zhang M, Sun SC (2005). An atypical tumor necrosis factor (TNF) receptor-associated factorbinding motif of B cell-activating factor belonging to the TNF family (BAFF) receptor mediates induction of the noncanonical NF-kappaB signaling pathway. J Biol Chem, 280, 10018-24.
  30. Nakano Y, Kobayashi W, Sugai S, Kimura H, Yagihashi S (1999). Expression of tumor necrosis factor-alpha and interleukin-6 in oral squamous cell carcinoma. Jpn J Cancer Res, 90, 858-66.
  31. Navazesh M (1993). Methods for collecting saliva. Annals New York Acad Sci, 694, 72-7.
  32. Partheniou F, Kelsey SM, Srinivasula SM, et al (2001). c-IAP1 blocks TNFalpha-mediated cytotoxicity upstream of caspase-dependent and -independent mitochondrial events in human leukemic cells. Biochem Biophys Res Commun, 287, 181-9.
  33. Patel SG, Shah JP (2005). TNM staging of cancers of the head and neck: striving for uniformity among diversity. CA Cancer J Clin, 55, 242-58.
  34. Patton LL, Epstein JB, Kerr AR (2008). Adjunctive techniques for oral cancer examination and lesion diagnosis: a systematic review of the literature. J Am Dent Assoc, 139, 896-905.
  35. Pfeffer K (2003). Biological functions of tumor necrosis factor cytokines and their receptors. Cytokine Growth Factor Rev, 14, 185-91.
  36. Pindborg JJ, Sirsat SM (1966). Oral submucous fibrosis. Oral Surg Oral Med Oral Pathol, 22, 764-79.
  37. Rafael N, Gideon B, Thomas S, Raphael F (2006). Concomitant analysis of salivary tumor markers. A new diagnostic tool for oral cancer. Clin Cancer Res, 12, 3979-84.
  38. Ramadas K, Sankaranarayanan R, Jacob BJ, et al (2003). Interim results from a cluster randomized controlled oral cancer screening trial in Kerala, India. Oral Oncol, 39, 580-8.
  39. Rhodus NL, Cheng B, Myers S, Miller L, Ho V, Ondrey F (2005). The feasibility of monitoring NF-kappaB associated cytokines: TNF-alpha, IL-1alpha, IL-6, and IL-8 in whole saliva for the malignant transformation of oral lichen planus. Molecular carcinogenesis, 44, 77-82.
  40. Rhodus NL, Ho V, Miller CS, Myers S, Ondrey F (2005). NFkappaB dependent cytokine levels in saliva of patients with oral preneoplastic lesions and oral squamous cell carcinoma. Cancer Detect Prev, 29, 42-5.
  41. Romero-Reyes M, Head C, Cacalano NA, Jewett A (2007). Potent induction of TNF-alpha during interaction of immune effectors with oral tumors as a potential mechanism for the loss of NK cell viability and function. Apoptosis, 12, 2063-75.
  42. Saheb Jamee M, Eslami M, Atarbashi-Moghadam F, Sarafnejad A (2008). Salivary concentration of TNFalpha, IL1 alpha, IL6, and IL8 in oral squamous cell carcinoma. Med Oral Patol Oral Cir Bucal, 13, 292-5.
  43. Saleh A, Kong YH, Vengu N, et al (2014). Dentists' perception of the role they play in early detection of oral cancer. Asian Pac J Cancer Prev, 15, 229-7.
  44. Shankar AA, Routray S (2012). Trends in salivary diagnostics - A 5-year review of oral oncology (2007-2011). Oral Oncol, 48, 22-3.
  45. Sherman ML, Spriggs DR, Arthur KA, et al (1988). Recombinant human tumor necrosis factor administered as a five-day continuous infusion in cancer patients: phase I toxicity and effects on lipid metabolism. J Clin Oncol, 6, 344-50.
  46. Su TR, Chang KL, Lee CH, et al (2004). Expression of tumor necrosis factor-alpha and its soluble receptors in betel-quidchewing patients at different stages of treatment for oral squamous cell carcinoma. Oral Oncol, 40, 804-10.
  47. Vijaya M, Malathi M, Shivashankara AR (2012). Lipid Peroxidation and antioxidant vitamin status in oral cavity and oropharyngeal cancer patients Asian Pac J Cancer Prev, 13, 5763-65.
  48. Warnakulasuriya S (2001). Histological grading of oral epithelial dysplasia: revisited. J Pathol, 194, 294-7.<294::AID-PATH911>3.0.CO;2-Q
  49. Warnakulasuriya S (2010). Living with oral cancer: epidemiology with particular reference to prevalence and life-style changes that influence survival. Oral Oncol, 46, 407-10.
  50. Watanabe N, Niitsu Y, Umeno H, Kuriyama H, Neda H, Yamauchi N, et al (1988). Toxic effect of tumor necrosis factor on tumor vasculature in mice. Cancer Res, 48, 2179-83.
  51. Yi-Shing LC, John W (2011). Advances in diagnostic adjuncts for oral squamous cell carcinoma. The Open Pathology J, 5, 3-7.
  52. Zhang A, Sun H, Wang P, Wang X (2013). Salivary proteomics in biomedical research. Clin Chim Acta, 415, 261-5.

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