Oral squamous carcinogenesis is a multistep process in which multiple genetic events occur that alter the normal function of oncogenes and tumor suppressor genes (tsg). Cancer related genes have to be considered in the context of six fundamental changes [1].

All normal cells require stimulation on the basis of signals to undergo growth, differentiation and proliferation; many of which carried by growth factors [1, 2]. EGFR plays an important role in the differentiation and morphogenesis of many organs and proliferation and survival in mammalian cells [3, 4]. EGFR has been reported to be expressed in a variety of human tumors of epithelial origin; over expression of EGFR has been documented in 80% of SCC [1].

Angiogenesis is a crucial step in the successful growth, invasion and metastasis of tumors, without which tumors will not grow more than 1-2 mm³ in diameter [5, 6]. VEGF has been considered as a leading candidate in the process of tumor angiogenesis. Various studies reported upregulation of VEGF in different malignancies [7, 8].

Tissue growth depends on both cell proliferation and the rate of cell death. PCNA is a 36 kd intra nuclear polypeptide protein whose expression is associated with DNA synthesis and cell proliferation. Many studies demonstrated an association of high expression rate of PCNA with poor prognosis in solid tumors [2, 9, 10].

Apoptosis is a process of programmed cell death, it is as essential as cell growth for the maintenance of homeostasis [2, 11]. P53 is a well known protein that regulates cell cycle check points and is responsible for maintaining the integrity of genome. Mutation of p53 tsg is one of the best known and by far the most frequent genetic alteration identified in malignant tumors [12].

Metastasis unequivocally signifies that a tumor is malignant. Lymphangiogenesis which refers to the growth of new lymphatic vessels has long been regarded as a putative efficient pathway to neoplastic metastasization [13, 14]. A new selective immunohistochemical marker is D2-40 which is specific for lymphatic endothelium since it doesn't stain vascular endothelium.

Tumors vary considerably in their behavior, notably in the rate of their growth, the degree of their differentiation and the ability to invade and metastasize. Because of the obscure and variable behavior of cancer, this study concerned different aspects of tumor dynamics through the immunohistochemcial evaluation of EGFR expression in OSCC and its correlation with proliferation, apoptosis, angiogenesis and lymphangiogensis via evaluating PCNA, p53, VEGF and D2- 40 Mabs immunohistochemically.

The study sample consisted of 40 retrospective OSCC specimens from the department of oral pathology, college of Dentistry, Baghdad University. An immunoshitochemcial staining with five types of Mabs was preformed: anti EGFR & VEGF (Dako Cytomation -Denmark), anti PCNA, anti P53 and anti D2-40 lymphatic endothelial marker (Dako Cytomation - USA). Negative and positive control slides were included in each IHC run (as recommended by the manufacturers).

It has been reported that the majority of head and neck cancer, including oral cancer express EGFR [20]. Since most oral cancers are epithelial in origin, it is reasonable that they should have a high probability of expressing EGFR. In this series most of the examined cases (87.5%) showed positive EGFR immunostaining. This finding is consistent with previous reports regarding the immunostaining and expression of EGFR in OSCC and other cancers [4, 17, 20].

A well controlled balance of cellular differentiation and proliferation is necessary for the development and maintenance of normal epithelia throughout the body; since OSCCs are epithelial malignancies, therefore, they should have a high probability of expressing EGFR. The present study confirms the observations of others that high EGFR expression is present in OSCCs which suggests that an uncontrolled growth may be mediated by abnormal EGFR expression [21].

EGFR expression extent and intensity scores revealed by most of the study cases suggest that EGFR expressing carcinomas display pathological features of more aggression which may be attributable to the activation of different signaling pathways that control diverse biological processes [4, 22].

EGFR expression involved all epithelial layers in OSCC specimens while in normal oral epithelia it was localized to the basal cell layer, similar results were reported by other investigators [20, 23]. Since the squamous epithelium keeps a continuous physiological regeneration in normal conditions, so that it is reasonable that the basal cells interpret signals of EGF by binding to EGFR [23], while its expression beyond basal localization in cancerous tissue suggests that a correlation between EGFR and tumor progress may exist.

The expression was mainly localized to the peripheries of tumor nests, this observation is in accordance with other studies [20, 23]. This finding confirms the presence of this receptor on undifferentiated cells and explains that the staining reaction varies with cellular differentiation. Moreover, it may explain that peripheral tumor cells receive a signal from EGF resulting in the proliferation of cancerous tissues.

D2-40 positive lymphatic vessels were recorded in 35 cases, similar results were found in OSCC and other cancers [18, 19, 24, 25], both peritumorally and intraumorally which suggests that these vessels could be a conduit for carcinoma cells and may contribute to lymph node metastasis.

LVI was observed in 13 cases in the current study. Other investigators reported similar findings in OSCC and other cancers [19, 24, 25]. This may reflect a significant role of these vessels in producing a possible route for the spread of tumor cells to regional lymph nodes.

Fifteen cases showed D2-40 expression by tumor cells, unfortunately there is no enough information concerning D2-40 expression in OSCC, therefore it is difficult to explain these results clearly. However, it may indicate a more aggressive disease phenotype and suggest that D2-40 may be implicated in the differentiation of SCC. Furthermore, D2-40 positive tumor cells were detected in the stromal tissue as well which suggests that it could act as a good marker for microinvasion in OSCC, finding worth more verification.

The current study showed no statistically significant differences between EGFR expression median scores and the clinicopatholgical findings; similar observations were reported in other studies [4, 17]. Furthermore, it was not correlated with the other markers as well (except D2-40) which indicate the independent effect of this marker on epithelial cancers development and growth. Moreover, the lack of correlation between EGFR extent or intensity scores in respect to VEGF expression but its existence in respect to LVD as shown in this study would favor lymphatic metastasis of OSCCs rather than hematogenous.

The results of the present study showed a statistically significant difference regarding LVI with respect to the median scores of ILVD, PLVD and TLVD. This finding probably reflects the close relationship between LVI and the lymphatic vessels since carcinomatous cells invade the lymphatic vessels which exist in the area to get an access to the regional lymph nodes. Furthermore, lack of correlation between LVD, LVI and D2-40 positive tumor cells may be attributed to the small size of node positive cases (12 out of 40).

Among all the available studies reviewed, to the best of our knowledge, the present work is the first of its kind in studying comprehensively these biomarkers all together, except several studies that assessed only two or three of them together [15, 21, 26, 27].

The results of this study clarify that the behavior of OSCC is not dependent on a single factor but its combination of multiple biological processes which are independent of each other i.e. malignancy follows no rules.