臺灣博碩士論文加值系統

中文摘要
由於近幾年來，對於口腔癌患者的治療與預後仍是相當不容易的，所以我們針對台大醫院患者進行追蹤性地研究，我們試圖在口腔癌前與口腔癌病患身上找出是否與各類口腔不良習慣(抽菸、喝酒、嚼食檳榔)及淋巴球細胞亞群的相關變異，存在著相互關聯。希望藉此研究口腔癌前病變與口腔癌患者其確定相關關係，並提供顯著的方向來治療以控制惡性轉變。不少研究顯示各類的化學致癌物質可以透過多種步驟達到誘導細胞DNA的破壞，造成基因毒性，細胞增殖，組織發炎等損害。在第一部分, 我們以C3H10T1/2細胞的癌化研究更進一步表明，檳榔的咀嚼會因為檳榔子萃取液(ANE)和檳榔生物鹼的細胞毒性，在口內可能影響傷口的癒合和產生發炎病症，甚至檳榔子成分可藉由其腫瘤啟始作用在口腔粘膜下纖維化與口腔癌的進程扮演重要角色。
其次化學刺激致癌已被證明是一種多步驟的癌化進程，包括腫瘤啟始，促進，增長和許多複雜交互的過程。在第二部份，我們研究28例口腔癌前病變患者，白斑（17例），口腔黏膜下纖維化（9例），口腔扁平苔蘚（1例），和紅斑（1例），最後有10位患者轉變為口腔癌。追蹤長達10年，針對了其年齡，TNM stage，各種口腔不良習慣等，以及利用流式細胞儀分析其淋巴細胞亞群（CD4 +，CD8 +，CD19 +，CD56 +和它們的活化標記物CD25和CD69）。 我們發現年齡和飲酒的差異，在細胞癌前病變與惡性病變過程是存在顯著關係的。淋巴球細胞亞群和活化的分佈是隨著疾病的進展不同而改變，在淋巴球細胞亞群的數值分析中， CD4+CD69+， CD19+CD69+ 和 CD56+CD69+ 表現，分別與惡性病變化有著統計上的相關聯性（p<0.05）。 CD4+，CD56+CD25+ 在惡性病變患者上則被發現有上升的趨勢（p<0.1）。不良習慣在口腔癌前病變的患者中，雖然無法明顯看出其個別習慣之間有明顯的促進細胞癌化病變的現象，但反過來看，沒有不良口腔習慣的癌前病患者，會有癌化病變的比例確實較少。
在第三部份，我們同樣收集分析86例口腔癌病患，最後統計有50位患者因癌症末期而死亡，而其中3年內的死亡率更達52%。在本組的調查中，罹癌死亡年齡層的高低與其死亡的比較，僅有些微的連結但並無明顯統計上的關係。而有無喝酒習慣的影響，則跟在癌前惡性病變的研究中一樣，亦是呈現正相關的連結，這並不表示檳榔與菸害的習慣對於口腔癌的傷害較為不大，只是在母群群的研究數量不大的情況下，沒有被強烈的顯示出來而已，另外根據統計，大部分罹患口腔癌的病患多為兼具多項不良口腔習慣的刺激，也因為大多數罹癌的患者都有這些習慣，才把這項指標鈍化了。此外，針對其淋巴細胞亞群CD19，CD56在罹癌患者的死亡分析上，也出現統計上的關聯，發現CD19的表現下降特別具有明顯的統計上差異，推測在免疫系統中代表B細胞於癌末患者的身上出現顯著弱化之現象，CD56+CD69+則在死亡患者群上有上升的趨勢性表現。這些結果皆顯示免疫系統會因為疾病的發展，而有所改變。所以，年齡、口腔習慣等、與其變化中的淋巴球細胞，T細胞，B細胞和NK細胞群等指標，確實是口腔癌發病機制的關鍵。所以淋巴球細胞群相關變化的分析，未來亦會是口腔癌中預測組織惡性病變與診斷的生物參考標誌。

English Abstract
In recent years, the prognosis for oral cancer patients is unpredictable even after different treatment modalities. We try to analyze whether betel quid (BQ) chewing, alcohol consumption and smoking habits may increase the risk of oral precancer and oral cancer. In addition, lymphocyte populations in patients may potentially affect the malignant transformation of oral pre-cancer in modern studies. We attempted to study whether oral habits or changes in lymphocyte subsets can be a biomarker for malignant transformation or cancer death in a cohort of patients with oral precancer and cancer. Moreover, a number of studies have found that chemical carcinogens may induce DNA damage, genotoxicity, cell proliferation and tissue inflammation and contribute to carcinogenesis. In the first part of study, we use C3H10T1/2 cell transformation assay to study the potential carcinogenicity of areca nut (AN). We showed that ANE and arecoline are cytotoxic to cells and may possibly affect the oral wound healing response. ANE exhibited tumor initiation effect and may induce transformation of C3H10T1/2 cells by the promotion of TPA. These effects may contribute to the pathogenesis of oral submucous fibrosis and oral cancer.
Various carcinogens may play important roles in specific steps of chemical carcinogenesis by inducing DNA damage, cytotoxicity, cell proliferation, tissue inflammation, impairment of cell-cell communication. In the 2nd Part，we enrolled 28 patients with oral pre-cancer and 86 oral cancer patients were enrolled in this study and their personal information and oral habits were documented. Their lymphocyte populations (CD4+, CD8+, CD19+, CD56+ and their activation marker CD25 and CD69) were determined by flow cytometry on 2002-2004. After follow-up to Dec. 2014, patients with/without malignant transformation were recorded and evaluated their relation to oral habits and percentage of initial lymphocyte markers.
Ten pre-cancer patients developed OSCC with a mean period of malignant transformation of 6.80 ± 2.13 years. Patients with malignant transformation showed mean age of 48.40 ± 4.97 (n=10), relatively higher than patients without malignant transformation (41.56 ± 6.27, n=18) (P<0.05). An increase in population of peripheral blood mononuclear cells expressing CD4+CD69+, CD19+CD69+, and CD56+CD69+ (p<0.05) in pre-cancer patients with malignant transformation was noted. Alcohol consumption showed an association with the malignant transformation of patients with pre-cancer (P=0.03), whereas BQ and smoking showed little effect. Conversely, we can find the ratio of malignant transformation without poor oral habits will be lower than patient with poor habits. It indicates the potential influence on oral carcinogenesis.
In the 3rd part, 86 cases of oral cancer patients, researched over 10 years, we also found that the age (p<0.1) is related between the oral cancer groups, and drinking habits statistically associated with the death group (p<0.05). There is no obvious relationship between the BQ chewing and smoking habits with oral cancer death. It does not mean that BQ and smoking habit have no influence on cancer death, because most cancer patients have both of these oral habits. Lymphocyte subpopulations CD19+ (p<0.01), have significant relationship in the survival and death groups, CD56+ (p=0.05), CD56+CD69+ (p=0.06) have the upregulation tendency in the death group. A decrease of CD19+ suggests that B cell declined significantly in the late cancer patients’ body. These results are displayed human immune system may change during tumor development. Finally, the end of the 50 cancer patients died, the mortality rate more than 52% within three years.
We concluded that areca nut components can be a tumor initiator, leading to the generation of initiated cells. Age and alcohol consumption, and the early activation of T cell, B cell and NK cells are crucial in the transformation of oral precancer to oral cancer. Moreover, age, alcohol consumption, and changes in B cells and NK cells in oral cancer patients are important for prediction of their future survival. Therefore, analysis of lymphocyte populations can be a diagnosis and an extra-prediction biomarker for malignant pathogenesis of oral cancer.

CONTENT
口試委員會審定書…………………………………………….…… 2
Acknowledgment…………..……………………………………..…. 3
Chinese Abstract………………………………………..…………… 4
English Abstract……..………………………………………………. 6
CHAPTER I --- Introduction……………………………..………….. 11
1. Etiology of oral cancer…………………………………………... 12
2. Immune and oral cancer……………………………………….… 13
3. Lymphocyte population and cancer……………………………... 15
4. CD4+CD3+ T cell, CD8+CD3+ T cell and B cell…………….. 16
5. Natural Killer cell (NK cell)…………………………………….. 17
6. Early and late marker in activation of lymphocytes…………….. 18
7. Chemical carcinogenesis………………………………………... 19
8. Hypothesis………………………………………………..……... 20
CHAPTER II --- Cytotoxicity and transformation of C3H10T1/2 cells induced by areca nut components ……….……….. 22
1. Abstract………………….………………………………….… 22
2. Introduction…………………………………………………… 24
3. Materials and Methods……………………………………..…. 26
4. Results………………………………………………………… 29
5. Discussion…………………………………………………….. 31


CHAPTER III --- Differences in oral habit and lymphocyte subpopulation affect malignant transformation of patients with oral pre-cancer………...……………………………..... 35
1. Abstract………………….………………………………….… 35
2. Introduction…………………………………………………… 37
3. Materials and Methods………………………………………... 40
4. Results………………………………………………………… 42
5. Discussion…………………………………………………….. 44
CHAPTER IV --- Factors affecting the survival of oral cancer patient ………………………………………....... 49
1. Abstract…………………………………………………..…… 49
2. Introduction…………………………………………………… 50
3. Materials and Methods………………………………………... 53
4. Results………………………………………………………… 55
5. Discussion…………………………………………………...... 57
CHAPTER V
1. Conclusion……………….……………………………………. 61
2. References.……………...………………...………….…..…… 65
3. Tables and Figures…..…………………….…………….……. 76

References
1.Badoual, C., F. Sandoval, H. Pere, S. Hans, A. Gey, N. Merillon, C. Van Ryswick, F. Quintin-Colonna, P. Bruneval, D. Brasnu, W.H. Fridman and E. Tartour, Better understanding tumor-host interaction in head and neck cancer to improve the design and development of immunotherapeutic strategies. Head Neck, 2010. 32(7): p. 946-58.
2.Barrett, J.C., Mechanisms of multistep carcinogenesis and carcinogen risk assessment. Environ Health Perspect, 1993. 100: p. 9-20.
3.Bauernhofer, T., I. Kuss, B. Henderson, A.S. Baum and T.L. Whiteside, Preferential apoptosis of CD56dim natural killer cell subset in patients with cancer. Eur J Immunol, 2003. 33(1): p. 119-24.
4.Berlinger, N.T., E.Y. Hilal, H.F. Oettgen and R.A. Good, Deficient cell-mediated immunity in head and neck cancer patients secondary to autologous suppressive immune cells. Laryngoscope, 1978. 88(3): p. 470-83.
5.Bogdanffy, M.S. and R. Valentine, Differentiating between local cytotoxicity, mitogenesis, and genotoxicity in carcinogen risk assessments: the case of vinyl acetate. Toxicol Lett, 2003. 140-141: p. 83-98.
6.Boreiko, C.J., Mechanistic aspects of initiation and promotion in C3H/10T1/2 cells. Carcinog Compr Surv, 1985. 9: p. 153-65.
7.Bureau of Health Promotion, D.o.H., DOH new cancer cases report (2008). Republic of China (ROC), 2008.
8.Chang, M.C., C.P. Chan, W.T. Wang, B.E. Chang, J.J. Lee, S.K. Tseng, S.Y. Yeung, L.J. Hahn and J.H. Jeng, Toxicity of areca nut ingredients: activation of CHK1/CHK2, induction of cell cycle arrest, and regulation of MMP-9 and TIMPs production in SAS epithelial cells. Head Neck, 2013. 35(9): p. 1295-302.
9.Chang, M.C., C.P. Chan, Y.J. Wang, P.H. Lee, L.I. Chen, Y.L. Tsai, B.R. Lin, Y.L. Wang and J.H. Jeng, Induction of necrosis and apoptosis to KB cancer cells by sanguinarine is associated with reactive oxygen species production and mitochondrial membrane depolarization. Toxicol Appl Pharmacol, 2007. 218(2): p. 143-51.
10.Chang, M.C., Y.J. Chen, H.H. Chang, C.P. Chan, C.Y. Yeh, Y.L. Wang, R.H. Cheng, L.J. Hahn and J.H. Jeng, Areca nut components affect COX-2, cyclin B1/cdc25C and keratin expression, PGE2 production in keratinocyte is related to reactive oxygen species, CYP1A1, Src, EGFR and Ras signaling. PLoS One, 2014. 9(7): p. e101959.
11.Chang, M.C., C.P. Chiang, C.L. Lin, J.J. Lee, L.J. Hahn and J.H. Jeng, Cell-mediated immunity and head and neck cancer: with special emphasis on betel quid chewing habit. Oral Oncol, 2005. 41(8): p. 757-75.
12.Chang, M.C., L.D. Lin, H.L. Wu, Y.S. Ho, H.C. Hsien, T.M. Wang, P.Y. Jeng, R.H. Cheng, L.J. Hahn and J.H. Jeng, Areca nut-induced buccal mucosa fibroblast contraction and its signaling: a potential role in oral submucous fibrosis--a precancer condition. Carcinogenesis, 2013. 34(5): p. 1096-104.
13.Chang, M.C., H.L. Wu, J.J. Lee, P.H. Lee, H.H. Chang, L.J. Hahn, B.R. Lin, Y.J. Chen and J.H. Jeng, The induction of prostaglandin E2 production, interleukin-6 production, cell cycle arrest, and cytotoxicity in primary oral keratinocytes and KB cancer cells by areca nut ingredients is differentially regulated by MEK/ERK activation. J Biol Chem, 2004. 279(49): p. 50676-83.
14.Chang, T.S., C.M. Chang, H.C. Ho, Y.C. Su, L.F. Chen, P. Chou and C.C. Lee, Impact of young age on the prognosis for oral cancer: a population-based study in Taiwan. PLoS One, 2013. 8(9): p. e75855.
15.Chen, P.H., Y.C. Ko, Y.H. Yang, Y.C. Lin, T.Y. Shieh, C.H. Chen and C.C. Tsai, Important prognostic factors of long-term oropharyngeal carcinoma survivors in Taiwan. Oral Oncol, 2004. 40(8): p. 847-55.
16.Chen, P.H., T.Y. Shieh, P.S. Ho, C.C. Tsai, Y.H. Yang, Y.C. Lin, M.S. Ko, P.C. Tsai, S.L. Chiang, H.P. Tu and Y.C. Ko, Prognostic factors associated with the survival of oral and pharyngeal carcinoma in Taiwan. BMC Cancer, 2007. 7: p. 101.
17.Chen, Y.J., J.T. Chang, C.T. Liao, H.M. Wang, T.C. Yen, C.C. Chiu, Y.C. Lu, H.F. Li and A.J. Cheng, Head and neck cancer in the betel quid chewing area: recent advances in molecular carcinogenesis. Cancer Sci, 2008. 99(8): p. 1507-14.
18.Chiba, T., H. Ohtani, T. Mizoi, Y. Naito, E. Sato, H. Nagura, A. Ohuchi, K. Ohuchi, K. Shiiba, Y. Kurokawa and S. Satomi, Intraepithelial CD8+ T-cell-count becomes a prognostic factor after a longer follow-up period in human colorectal carcinoma: possible association with suppression of micrometastasis. Br J Cancer, 2004. 91(9): p. 1711-7.
19.Chung, C.H., Y.H. Yang, T.Y. Wang, T.Y. Shieh and S. Warnakulasuriya, Oral precancerous disorders associated with areca quid chewing, smoking, and alcohol drinking in southern Taiwan. J Oral Pathol Med, 2005. 34(8): p. 460-6.
20.Das, S.N., N.N. Khanna and S. Khanna, In vivo and in vitro observation of cellular immune parameters in squamous cell carcinoma of the oral cavity and its correlation with tumor load and prognosis. Cancer Invest, 1986. 4(3): p. 207-16.
21.Desai, S.S., S.D. Ghaisas, S.D. Jakhi and S.V. Bhide, Cytogenetic damage in exfoliated oral mucosal cells and circulating lymphocytes of patients suffering from precancerous oral lesions. Cancer Lett, 1996. 109(1-2): p. 9-14.
22.dos antos Pereira, J., M.C. da Costa Miguel, L.M. Guedes Queiroz and E.J. da Silveira, Analysis of CD8+ and CD4+ cells in oral squamous cell carcinoma and their association with lymph node metastasis and histologic grade of malignancy. Appl Immunohistochem Mol Morphol, 2014. 22(3): p. 200-5.
23.Dunn, G.P., L.J. Old and R.D. Schreiber, The immunobiology of cancer immunosurveillance and immunoediting. Immunity, 2004. 21(2): p. 137-48.
24.Eriksson, L., M. Ahluwalia, J. Spiewak, G. Lee, D.S. Sarma, M.J. Roomi and E. Farber, Distinctive biochemical pattern associated with resistance of hepatocytes in hepatocyte nodules during liver carcinogenesis. Environ Health Perspect, 1983. 49: p. 171-4.
25.Feller, L., R. Chandran, R.A. Khammissa, R. Meyerov and J. Lemmer, Alcohol and oral squamous cell carcinoma. SADJ, 2013. 68(4): p. 176-80.
26.Franceschi, S., R. Talamini, S. Barra, A.E. Baron, E. Negri, E. Bidoli, D. Serraino and C. La Vecchia, Smoking and drinking in relation to cancers of the oral cavity, pharynx, larynx, and esophagus in northern Italy. Cancer Res, 1990. 50(20): p. 6502-7.
27.Gannot, G., I. Gannot, H. Vered, A. Buchner and Y. Keisari, Increase in immune cell infiltration with progression of oral epithelium from hyperkeratosis to dysplasia and carcinoma. Br J Cancer, 2002. 86(9): p. 1444-8.
28.Gao, Y.J., X.M. Yin and H.J. Wu, [Relationship between vertical root fracture and the habits of chewing betel nut]. Hunan Yi Ke Da Xue Xue Bao, 2001. 26(2): p. 161-2.
29.Grisham, M.B., D. Jourd''heuil and D.A. Wink, Review article: chronic inflammation and reactive oxygen and nitrogen metabolism--implications in DNA damage and mutagenesis. Aliment Pharmacol Ther, 2000. 14 Suppl 1: p. 3-9.
30.Han, Y., Y. Yang, Z. Chen, Z. Jiang, Y. Gu, Y. Liu, S. Xu, C. Lin, Z. Pan, W. Zhou and X. Cao, Human hepatocellular carcinoma-infiltrating CD4(+)CD69(+)Foxp3(-) regulatory T cell suppresses T cell response via membrane-bound TGF-beta1. J Mol Med (Berl), 2014. 92(5): p. 539-50.
31.Heimdal, J.H., H.J. Aarstad, B. Klementsen and J. Olofsson, Peripheral blood mononuclear cell (PBMC) responsiveness in patients with head and neck cancer in relation to tumour stage and prognosis. Acta Otolaryngol, 1999. 119(2): p. 281-4.
32.Hirota, J., E. Ueta, T. Osaki and Y. Ogawa, Immunohistologic study of mononuclear cell infiltrates in oral squamous cell carcinomas. Head Neck, 1990. 12(2): p. 118-25.
33.Hsieh, L.L., P.F. Wang, I.H. Chen, C.T. Liao, H.M. Wang, M.C. Chen, J.T. Chang and A.J. Cheng, Characteristics of mutations in the p53 gene in oral squamous cell carcinoma associated with betel quid chewing and cigarette smoking in Taiwanese. Carcinogenesis, 2001. 22(9): p. 1497-503.
34.IARC, "Betel-quid and areca-nut chewing and some areca-nut derived nitrosamines". IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2004. 85: p. 1-334.
35.Jefferies, S., R. Eeles, D. Goldgar, R. A''Hern, J.M. Henk and M. Gore, The role of genetic factors in predisposition to squamous cell cancer of the head and neck. Br J Cancer, 1999. 79(5-6): p. 865-7.
36.Jeng, J.H., M.C. Chang and L.J. Hahn, Role of areca nut in betel quid-associated chemical carcinogenesis: current awareness and future perspectives. Oral Oncol, 2001. 37(6): p. 477-92.
37.Jeng, J.H., Y.S. Ho, C.P. Chan, Y.J. Wang, L.J. Hahn, D. Lei, C.C. Hsu and M.C. Chang, Areca nut extract up-regulates prostaglandin production, cyclooxygenase-2 mRNA and protein expression of human oral keratinocytes. Carcinogenesis, 2000. 21(7): p. 1365-70.
38.Jeng, J.H., M.L. Kuo, L.J. Hahn and M.Y. Kuo, Genotoxic and non-genotoxic effects of betel quid ingredients on oral mucosal fibroblasts in vitro. J Dent Res, 1994. 73(5): p. 1043-9.
39.Jewett, A., C. Head and N.A. Cacalano, Emerging mechanisms of immunosuppression in oral cancers. J Dent Res, 2006. 85(12): p. 1061-73.
40.Ji, W.T., C.I. Lee, J.Y. Chen, Y.P. Cheng, S.R. Yang, J.H. Chen and H.R. Chen, Areca nut extract induces pyknotic necrosis in serum-starved oral cells via increasing reactive oxygen species and inhibiting GSK3beta: an implication for cytopathic effects in betel quid chewers. PLoS One, 2013. 8(5): p. e63295.
41.Jin, Y.T., S.T. Tsai, T.Y. Wong, F.F. Chen and R.M. Chen, Studies on promoting activity of Taiwan betel quid ingredients in hamster buccal pouch carcinogenesis. Eur J Cancer B Oral Oncol, 1996. 32B(5): p. 343-6.
42.Klaunig, J.E., L.M. Kamendulis and Y. Xu, Epigenetic mechanisms of chemical carcinogenesis. Hum Exp Toxicol, 2000. 19(10): p. 543-55.
43.Ko, Y.C., T.A. Chiang, S.J. Chang and S.F. Hsieh, Prevalence of betel quid chewing habit in Taiwan and related sociodemographic factors. J Oral Pathol Med, 1992. 21(6): p. 261-4.
44.Ko, Y.C., Y.L. Huang, C.H. Lee, M.J. Chen, L.M. Lin and C.C. Tsai, Betel quid chewing, cigarette smoking and alcohol consumption related to oral cancer in Taiwan. J Oral Pathol Med, 1995. 24(10): p. 450-3.
45.Koebel, C.M., W. Vermi, J.B. Swann, N. Zerafa, S.J. Rodig, L.J. Old, M.J. Smyth and R.D. Schreiber, Adaptive immunity maintains occult cancer in an equilibrium state. Nature, 2007. 450(7171): p. 903-7.
46.Kohle, C., M. Schwarz and K.W. Bock, Promotion of hepatocarcinogenesis in humans and animal models. Arch Toxicol, 2008. 82(9): p. 623-31.
47.Lee, J.J., H.C. Hung, S.J. Cheng, Y.J. Chen, C.P. Chiang, B.Y. Liu, J.H. Jeng, H.H. Chang, Y.S. Kuo, W.H. Lan and S.H. Kok, Carcinoma and dysplasia in oral leukoplakias in Taiwan: prevalence and risk factors. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2006. 101(4): p. 472-80.
48.Lee, J.J., C.L. Lin, T.H. Chen, S.H. Kok, M.C. Chang and J.H. Jeng, Changes in peripheral blood lymphocyte phenotypes distribution in patients with oral cancer/oral leukoplakia in Taiwan. Int J Oral Maxillofac Surg, 2010. 39(8): p. 806-14.
49.Lehane, M.M., P.E. Bryant, A.C. Riches, L.A. Allen, C.V. Briscoe, J. Melville and A.J. Mill, 238Pu alpha-particle-induced C3H10T1/2 transformants are less tumorigenic than the X-ray-induced equivalent. Carcinogenesis, 1999. 20(1): p. 35-40.
50.Lin, C.L., J.J. Lee, H.H. Chang, J.H. Jeng and Y.S. Kuo, Evaluation of lymphocyte subsets in healthy subjects and patients with advanced or terminal oral cancer. Chin Dent J, 2004. 23(5): p. 379-85.
51.Lin, L.M., Y.K. Chen, D.R. Lai, Y.L. Huang and H.R. Chen, Cancer-promoting effect of Taiwan betel quid in hamster buccal pouch carcinogenesis. Oral Dis, 1997. 3(4): p. 232-5.
52.Lin, M.H., F.P. Chou, H.P. Huang, J.D. Hsu, M.Y. Chou and C.J. Wang, The tumor promoting effect of lime-piper betel quid in JB6 cells. Food Chem Toxicol, 2003. 41(11): p. 1463-71.
53.Lin, M.H., C.J. Wang, H.P. Huang, M.Y. Chou and F.P. Chou, The tumorigenic characteristics of lime-piper betel quid-transformed JB6 cells. Arch Toxicol, 2004. 78(3): p. 167-73.
54.Ling, L.J., S.L. Hung, S.C. Tseng, Y.T. Chen, L.Y. Chi, K.M. Wu and Y.L. Lai, Association between betel quid chewing, periodontal status and periodontal pathogens. Oral Microbiol Immunol, 2001. 16(6): p. 364-9.
55.Liu, S.Y., C.L. Lu, C.T. Chiou, C.Y. Yen, G.A. Liaw, Y.C. Chen, Y.C. Liu and W.F. Chiang, Surgical outcomes and prognostic factors of oral cancer associated with betel quid chewing and tobacco smoking in Taiwan. Oral Oncol, 2010. 46(4): p. 276-82.
56.Liu, Y., H. Chen, Z. Sun and X. Chen, Molecular mechanisms of ethanol-associated oro-esophageal squamous cell carcinoma. Cancer Lett, 2015. 361(2): p. 164-73.
57.Lo, W.L., S.Y. Kao, L.Y. Chi, Y.K. Wong and R.C. Chang, Outcomes of oral squamous cell carcinoma in Taiwan after surgical therapy: factors affecting survival. J Oral Maxillofac Surg, 2003. 61(7): p. 751-8.
58.Minamoto, T., M. Mai and Z. Ronai, Environmental factors as regulators and effectors of multistep carcinogenesis. Carcinogenesis, 1999. 20(4): p. 519-27.
59.Parfett, C., J. Macmillan and R. Pilon, Oxidative stress mediates tumor promoter-induced proliferin gene-expression in c3h10t1/2 cells. Int J Oncol, 1993. 3(5): p. 917-25.
60.Pezzilli, R., M. Maldini, A.M. Morselli-Labate, B. Barakat, E. Romboli, E. Beltrandi, M. Migliori, P. Tomassetti and R. Corinaldesi, Early activation of peripheral lymphocytes in human acute pancreatitis. J Clin Gastroenterol, 2003. 36(4): p. 360-3.
61.Pillai, M.R., P. Balaram, T. Abraham and M.K. Nair, Lymphocyte populations in premalignant lesions and cancer of the oral cavity. Neoplasma, 1987. 34(4): p. 469-79.
62.Pillai, R., P. Balaram and K.S. Reddiar, Immunological abnormalities in oral precancers. Cancer Lett, 1991. 57(1): p. 1-6.
63.Prince, S. and B.M. Bailey, Squamous carcinoma of the tongue: review. Br J Oral Maxillofac Surg, 1999. 37(3): p. 164-74.
64.Reznikoff, C.A., J.S. Bertram, D.W. Brankow and C. Heidelberger, Quantitative and qualitative studies of chemical transformation of cloned C3H mouse embryo cells sensitive to postconfluence inhibition of cell division. Cancer Res, 1973. 33(12): p. 3239-49.
65.Rincon-Arevalo, H., C.C. Sanchez-Parra, D. Castano, L. Yassin and G. Vasquez, Regulatory B Cells and Mechanisms. Int Rev Immunol, 2015.
66.Saranath, D., R. Mukhopadhyaya, R.S. Rao, A.R. Fakih, S.L. Naik and S.G. Gangal, Cell-mediated immune status in patients with squamous cell carcinoma of the oral cavity. Cancer, 1985. 56(5): p. 1062-70.
67.Senovilla, L., I. Vitale, I. Martins, M. Tailler, C. Pailleret, M. Michaud, L. Galluzzi, S. Adjemian, O. Kepp, M. Niso-Santano, S. Shen, G. Marino, A. Criollo, A. Boileve, B. Job, S. Ladoire, F. Ghiringhelli, A. Sistigu, T. Yamazaki, S. Rello-Varona, C. Locher, V. Poirier-Colame, M. Talbot, A. Valent, F. Berardinelli, A. Antoccia, F. Ciccosanti, G.M. Fimia, M. Piacentini, A. Fueyo, N.L. Messina, M. Li, C.J. Chan, V. Sigl, G. Pourcher, C. Ruckenstuhl, D. Carmona-Gutierrez, V. Lazar, J.M. Penninger, F. Madeo, C. Lopez-Otin, M.J. Smyth, L. Zitvogel, M. Castedo, and G. Kroemer, An immunosurveillance mechanism controls cancer cell ploidy. Science, 2012. 337(6102): p. 1678-84.
68.Shiu, M.N. and T.H. Chen, Impact of betel quid, tobacco and alcohol on three-stage disease natural history of oral leukoplakia and cancer: implication for prevention of oral cancer. Eur J Cancer Prev, 2004. 13(1): p. 39-45.
69.Shiu, M.N., T.H. Chen, S.H. Chang and L.J. Hahn, Risk factors for leukoplakia and malignant transformation to oral carcinoma: a leukoplakia cohort in Taiwan. Br J Cancer, 2000. 82(11): p. 1871-4.
70.Short, B.G., Cell proliferation and renal carcinogenesis. Environ Health Perspect, 1993. 101 Suppl 5: p. 115-20.
71.Siegel, R.L., L. Sahar, K.M. Portier, E.M. Ward and A. Jemal, Cancer death rates in US congressional districts. CA Cancer J Clin, 2015.
72.Torgovnick, A. and B. Schumacher, DNA repair mechanisms in cancer development and therapy. Front Genet, 2015. 6: p. 157.
73.Tsang, S.S., H.F. Stich and H. Fujiki, Cell transformation induced by bovine papillomavirus DNA as an assay for tumor promoters and chemopreventive agents. Cancer Detect Prev, 1991. 15(5): p. 423-7.
74.Vokes, E.E., R.R. Weichselbaum, S.M. Lippman and W.K. Hong, Head and neck cancer. N Engl J Med, 1993. 328(3): p. 184-94.
75.Wadia, P., D. Rao, T. Pradhan, A. Pathak and S. Chiplunkar, Impaired lymphocyte responses and their restoration in oral cancer patients expressing distinct TCR variable region. Cancer Invest, 2008. 26(5): p. 471-80.
76.Wagner, W., C.I. Weidner and Q. Lin, Do age-associated DNA methylation changes increase the risk of malignant transformation? Bioessays, 2015. 37(1): p. 20-4.
77.Wang, Y.Y., Y.H. Tail, W.C. Wang, C.Y. Chen, Y.H. Kao, Y.K. Chen and C.H. Chen, Malignant transformation in 5071 southern Taiwanese patients with potentially malignant oral mucosal disorders. BMC Oral Health, 2014. 14: p. 99.
78.Warnakulasuriya, S., T. Kovacevic, P. Madden, V.H. Coupland, M. Sperandio, E. Odell and H. Moller, Factors predicting malignant transformation in oral potentially malignant disorders among patients accrued over a 10-year period in South East England. J Oral Pathol Med, 2011. 40(9): p. 677-83.
79.Watanabe, Y., F. Katou, H. Ohtani, T. Nakayama, O. Yoshie and K. Hashimoto, Tumor-infiltrating lymphocytes, particularly the balance between CD8(+) T cells and CCR4(+) regulatory T cells, affect the survival of patients with oral squamous cell carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2010. 109(5): p. 744-52.
80.Whiteside, T.L., The tumor microenvironment and its role in promoting tumor growth. Oncogene, 2008. 27(45): p. 5904-12.
81.Wolf, G.T., D.B. Chepeha, E. Bellile, A. Nguyen, D. Thomas, J. McHugh, H. University of Michigan and S.P. Neck, Tumor infiltrating lymphocytes (TIL) and prognosis in oral cavity squamous carcinoma: a preliminary study. Oral Oncol, 2015. 51(1): p. 90-5.
82.Wolfle, D., Enhancement of carcinogen-induced malignant cell transformation by prostaglandin F(2 alpha). Toxicology, 2003. 188(2-3): p. 139-47.
83.Ye, D.X., Q. Xu, W.T. Chen, H.G. Zhu, G.C. Lin, C.H. Jiang and W.L. Qiu, [Immunodetections and analysis of peripheral blood for patients with oral cancer undergoing operation]. Shanghai Kou Qiang Yi Xue, 2004. 13(2): p. 83-6.
84.Yeh, C.Y., H.M. Chen, M.C. Chang, S.H. Kok, J.J. Lee, B.E. Chang, P.Y. Jeng, C.P. Chan and J.H. Jeng, Cytotoxicity and transformation of C3H10T1/2 cells induced by areca nut components. J Formos Med Assoc, 2015.
85.Yen, A.M., S.C. Chen, S.H. Chang and T.H. Chen, The effect of betel quid and cigarette on multistate progression of oral pre-malignancy. J Oral Pathol Med, 2008. 37(7): p. 417-22.
86.Zamarron, B.F. and W. Chen, Dual roles of immune cells and their factors in cancer development and progression. Int J Biol Sci, 2011. 7(5): p. 651-8.
87.Ziegler, S.F., F. Ramsdell and M.R. Alderson, The activation antigen CD69. Stem Cells, 1994. 12(5): p. 456-65.
88.Zitvogel, L., A. Tesniere and G. Kroemer, Cancer despite immunosurveillance: immunoselection and immunosubversion. Nat Rev Immunol, 2006. 6(10): p. 715-27.