biology

Systematic Review
Overexpression of E-Cadherin Is a Favorable Prognostic
Biomarker in Oral Squamous Cell Carcinoma: A Systematic
Review and Meta-Analysis
Alejandro I. Lorenzo-Pouso 1 , Fábio França-Vieira e Silva 1,2 , Alba Pérez-Jardón 1,2 ,
Cintia M. Chamorro-Petronacci 1,2 , Mônica G. Oliveira-Alves 3,4 , Óscar Álvarez-Calderón-Iglesias 5,6 ,
Vito Carlo Alberto Caponio 7, * , Morena Pinti 8 , Vittoria Perrotti 8 and Mario Pérez-Sayáns 1,2

1 Oral Medicine, Oral Surgery and Implantology Unit (MedOralRes), Faculty of Medicine and Dentistry,
Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain
2 ORALRES Group, Health Research Institute of Santiago de Compostela (FIDIS),
15782 Santiago de Compostela, Spain
3 Technology Research Center (NPT), Universidade Mogi das Cruzes, Mogi das Cruzes 12245-000, SP, Brazil
4 School of Medicine, Anhembi Morumbi University, São José dos Campos 12247-004, SP, Brazil
5 Research, Health and Podiatry Group, Department of Health Sciences, Faculty of Nursing and Podiatry,
University of A Coruña, 15008 A Coruña, Spain
6 HM Hospitals Research Foundation, 28015 Madrid, Spain
7 Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy
8 Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” Chieti-Pescara,
66100 Chieti, Italy
* Correspondence: [email protected]; Tel.: +39-0881588082

Simple Summary: An oral cavity tumor, known as an oral squamous cell carcinoma (OSCC), has a
Citation: Lorenzo-Pouso, A.I.; Silva,
five-year survival rate of just about 50%. Novel, easily, available biomarkers for prognosis evaluation
F.F.-V.e.; Pérez-Jardón, A.;
are still required. Despite advancements in diagnosis and therapy, this rate has not grown in recent
Chamorro-Petronacci, C.M.;
Oliveira-Alves, M.G.;
decades. Our study indicated that a lower expression of a protein named E-cadherin is related
Álvarez-Calderón-Iglesias, Ó.; with a poor prognosis for OSCC patients. This evidence came from the meta-analysis of 25 studies,
Caponio, V.C.A.; Pinti, M.; Perrotti, V.; including 2553 patients, in which E-cadherin protein expression was assessed in their tumor sample
Pérez-Sayáns, M. Overexpression of by immunohistochemistry. This study highlights the promising role of E-cadherin assessment during
E-Cadherin Is a Favorable Prognostic routine histopathology diagnoses to support prognostic decision-making, and to pave the way for
Biomarker in Oral Squamous Cell future studies to counteract its role in cancer progression.
Carcinoma: A Systematic Review and
Meta-Analysis. Biology 2023, 12, 239. Abstract: Oral squamous cell carcinoma (OSCC) is characterized by poor survival, mostly due to
https://doi.org/10.3390/ local invasion, loco-regional recurrence, and metastasis. Given that the weakening of cell-to-cell
biology12020239
adhesion is a feature associated with the migration and invasion of cancer cells, different studies
Academic Editor: Barry James have explored the prognostic utility of cell adhesion molecules such as E-cadherin (E-cad). This
Campbell study aims to summarize current evidence in a meta-analysis, focusing on the prognostic role of
E-cad in OSCC. To find studies meeting inclusion criteria, Scopus, Web of Science, EMBASE, Medline,
Received: 5 December 2022
and OpenGrey databases were systematically assessed and screened. The selection process led to
Revised: 27 January 2023
Accepted: 30 January 2023
25 studies, which were considered eligible for inclusion in the meta-analysis, representing a sample
Published: 2 February 2023 of 2553 patients. E-cad overexpression was strongly associated with longer overall survival (OS) with
Hazard Ratio (HR) = 0.41 95% confidence interval (95% CI) (0.32–0.54); p < 0.001 and disease-free
survival with HR 0.47 95% CI (0.37–0.61); p < 0.001. In terms of OS, patients with tongue cancer
experienced better survivability when expressing E-cad with HR 0.28 95% CI (0.19–0.43); p < 0.001.
Copyright: © 2023 by the authors. Globally, our findings indicate the prognostic role of the immunohistochemical assessment of E-cad
Licensee MDPI, Basel, Switzerland.
in OSCC and its expression might acquire a different role based on the oral cavity subsites.
This article is an open access article
distributed under the terms and
Keywords: E-cadherin; epithelial-mesenchymal transition; mouth neoplasm; prognostic; systematic
conditions of the Creative Commons
review; meta-analysis
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

Biology 2023, 12, 239. https://doi.org/10.3390/biology12020239 https://www.mdpi.com/journal/biology

Biology 2023, 12, 239 2 of 18

1. Introduction
Worldwide, oral squamous cell carcinoma (OSCC) is a growing health problem. The
prognosis for patients affected by this neoplasm remains mainly based on the TNM sys-
tem [1]. Therapeutics have improved during recent decades, although these efforts remain
suboptimal, owing to the remaining 5-year survival rate of around 50–60%. These long-term
outcomes are even poorer in tumors at advanced stages, mainly due to poor locoregional
control and the increased odds of distant metastasis development [2]. Recent initiatives
have addressed the identification of biomarkers to complement prognosis assessment from
a molecular point-of-view to study biological tumor behavior, but also in the search for
novel therapeutic targets [3–5]. In the last decade, the number of studies that focused on
the prognostic value of immunohistochemical (IHC) biomarkers has increased. Among
these, one of the most studied biological mechanisms underlying OSCC is epithelial–
mesenchymal transition (EMT) [6]. EMT includes epithelial cells showing mesenchymal
traits and characteristics [7]. This EMT-related phenotype switches results in a cascade of
aberrant signaling pathways such as TFG-β, Wnt signaling or notch, and aberrant stemness
properties [8,9]. Specially, EMT is mainly driven by a molecular machinery of glycoproteins
that mediate intercellular adhesion via calcium-dependent binding; among these, the main
family of proteins involved are cadherins [10–12]. The protein product of the gene CDH1 is
one of the most studied in OSCC and EMT. The CDH1 gene is in the 16q22.1 chromosomal
band and its protein product is E-Cadherin (E-cad). E-cad is important in maintaining
oral epithelial cell homeostasis and physiology [13]. Different studies showed that E-cad
inactivation triggers a decrease in cell–cell contact, followed by the loss of cell polarity,
differentiation, and a gain in growth and cell migration (Figure 1) [14,15].
E-cad is a well-characterized molecular marker of EMT, and changes in its expression
have been related to the detrimental prognosis of several solid tumors [16]. Association
between reduced E-cad expression and poor survival was found in a previously published
meta-analysis in head and neck [17], esophageal [18], and gastric cancer [19]. Several molec-
ular processes contribute to decreased E-cad expression, linked to the onset and progression
of different cancers. The promoter hypermethylation, a crucial tumor suppressor–silencing
mechanism, has been linked significantly to decreased E-cad expression [20]. Furthermore,
reduced expression of E-cad can be a consequence of somatic and germline mutations [21].
Additionally, new research has demonstrated that downregulation occurs as a result of
the activation of E-cad transcriptional repressors such as Snail and Slug [22,23]. Several
microRNAs, including those in the miR-200 family and miR-101, have been found to sup-
press E-cad by upregulating the expression of E-cad repressors when their expression is
decreased or deleted [24,25]. These mechanisms differentially contribute to lower E-cad
expression, leading to cancer onset and progression.
Nonetheless, the association between E-cad IHC-based expression and long-term
outcomes has proved controversial according to previous meta-analyses regarding head
and neck squamous cell carcinomas [17]. The only meta-analysis carried out specifically in
OSCC presented several drawbacks, such as the exclusion of subgroup analysis.
Therefore, the aim of this systematic review and meta-analysis was to further investi-
gate the potential role of E-cad immunohistochemical expression to serve as a prognostic
factor for long-term outcomes related to survival in OSCC.
Biology 2023,
Biology 12,12,
2023, x FOR
239 PEER REVIEW 33ofof
18 18

Figure 1. The descriptive diagram model of composition and interactions between proteins that
are part
Figure 1. of
Thethe cell union diagram
descriptive complex.model(A) The of Occlusion
composition Junctions seal the spaces
and interactions between
between epithelial
proteins that are
part
cells,ofand
the cell
it is union complex.importance
of paramount (A) The Occlusion
in sealing Junctions seal the
the epithelial spaces
tissues tobetween epithelialand
water molecules cells,
and
ions,it is of paramount
making the passiveimportance
diffusioninof sealing the epithelial
ions impossible; tissues
here to water
Occludins andmolecules
Claudinsand act. ions, mak‐
(B) The
ing the passive
Adherens diffusion
Junctions connect of ions impossible;
the bundles here
of Actin Occludins
Filaments andcell
of one Claudins
with theact. (B) The
bundles of Adherens
another
Junctions
cell where connect the bundles
the primary function ofisActin Filaments
to promote of onebetween
adhesion cell withneighboring
the bundlescellsof another cell where
being crucial in
the primary function is to promote adhesion between neighboring cells being
tissue architecture; here Cadherins, α-Catenins, β-Catenins, p120-Catenin, and Vinculins acts. The crucial in tissue archi‐
tecture;
regulation hereofCadherins,
the cell–cell α‐Catenins,
adhesion complexβ‐Catenins, p120‐Catenin,
is mediated and Vinculins
by E-Cadherin acts.the
and can favor The regulation
transforma-
of the cell–cell adhesion complex is mediated by E‐Cadherin and can favor the transformation of
tion of epithelial cells into mesenchymal cells after triggering EMT inducers in the various pathways
epithelial cells into mesenchymal cells after triggering EMT inducers in the various pathways in‐
involved; among those involved, the SNAIL protein helps to promote this process by blocking the
volved; among those involved, the SNAIL protein helps to promote this process by blocking the E‐
E-Cadherin. (C) Desmosomes connect the Intermediate Filaments of one cell with those of the other
Cadherin. (C) Desmosomes connect the Intermediate Filaments of one cell with those of the other
cell,with
cell, with the
the main
mainaim aimofofpromoting
promoting intercellular
intercellularadhesion, not interfering
adhesion, with other
not interfering with junctions; here
other junctions;
Desmogleins, Desmocolins, Plakoglobin, Desmoplakin, and the Intermediate
here Desmogleins, Desmocolins, Plakoglobin, Desmoplakin, and the Intermediate Filaments are in‐ Filaments are involved.
(D) The(D)
volved. GapTheJunctions allow theallow
Gap Junctions passagethe of water-soluble
passage moleculesmolecules
of water‐soluble from one cell
fromto one
another; it isan‐
cell to
formed by six subunits of Connexins forming a hexagonal complex. (E)
other; it is formed by six subunits of Connexins forming a hexagonal complex. (E) Hemidesmosomes Hemidesmosomes anchor
the cell’s
anchor theIntermediate Filaments
cell’s Intermediate to the to
Filaments Extracellular Matrix—Cell/Matrix
the Extracellular Matrix—Cell/Matrix adhesion anchors
adhesion the
anchors
the Actin
Actin Filaments
Filaments of the
of the cell cell to Extracellular
to the the Extracellular Matrix,
Matrix, connecting
connecting the Intermediate
the Intermediate Filaments
Filaments of the of
the Cytoskeleton
Cytoskeleton withwith
the the Extracellular
Extracellular Matrix;
Matrix; here here α‐Integrins
α-Integrins and β‐Integrins
and β-Integrins are involved.
are involved.

2. Materials
E‐cad is aand Methods
well‐characterized molecular marker of EMT, and changes in its expression
Beforerelated
have been performing
to thethe systematic review,
detrimental its protocol
prognosis wassolid
of several registered
tumorsin [16].
the PROSPERO
Association
database (CRD42020201631). This systematic review and meta-analysis comply
between reduced E‐cad expression and poor survival was found in a previously published with
PRISMA [26] and MOOSE guidelines [27].
meta‐analysis in head and neck [17], esophageal [18], and gastric cancer [19]. Several mo‐
The
lecular researchcontribute
processes question was developed E‐cad
to decreased according to the PICO
expression, framework:
linked What
to the onset is the
and pro‐
prognostic significance of E-Cadherin immunohistochemical expression in patients
gression of different cancers. The promoter hypermethylation, a crucial tumor suppres‐ with
OSCC? This is in accordance with the PICO method: population (adults), intervention
sor–silencing mechanism, has been linked significantly to decreased E‐cad expression
(E-cadherin overexpression), comparison (E-cadherin subexpression), outcome (long-term
[20]. Furthermore, reduced expression of E‐cad can be a consequence of somatic and
outcomes/survival).
germline mutations [21]. Additionally, new research has demonstrated that downregula‐
tion occurs as a result of the activation of E‐cad transcriptional repressors such as Snail
and Slug [22,23]. Several microRNAs, including those in the miR‐200 family and miR‐101,
Biology 2023, 12, 239 4 of 18

2.1. Search Strategy

References were screened from different databases. The Web of Science, Scopus,
Medline via PubMed, EMBASE, and Grey Literature Database were accessed (accessed on
30 July 2022). Searches were conducted by combining MeSH and EMTREE terms used by
the databases and general text words. The following algorithm was applied to Medline:
(“E-cadherin” [MeSH Terms]) OR (“cadherin” [All Fields] AND “E-cad” [All Fields]) OR
(“epithelial cadherin” [All Fields]) AND (“mouth” [MeSH Terms] OR “mouth” [All Fields]
OR “oral” [All Fields]) AND (“carcinoma, squamous cell” [MeSH Terms]) OR (“carcinoma”
[All Fields] AND “squamous” [All Fields] AND “cell” [All Fields]) OR (“squamous cell
carcinoma” [All Fields]). This syntax was conveniently adapted for each database.
A supplemental manual search was also conducted in journals relating to oral pathol-
ogy, oral/maxillofacial surgery, oral medicine, and oncology. Reference lists from the
retrieved papers as well as potentially pertinent articles that any of the writers were fa-
miliar with were thoroughly verified. All references retrieved were managed using the
software EndNote X9 (Clarivate, PA, USA), and duplicated references were also deleted
with this software.

2.2. Eligibility Criteria

An ad hoc review group was composed by two experts in oral pathology (AILP
and MPS). The study selection was carried out in two screening phases. First, these
two authors independently evaluated titles and abstracts of resulting studies, further
solving disagreements in a consensus meeting. Subsequently, full-text studies were blindly
appraised by the same authors and the information was again cross-checked. Freeware
Epidat 4.2 (Software for Epidemiological Analysis of Tabulated Data. www.sergas.es/
saude-publica/EPIDAT accessed on 30 July 2022) was used to calculate Cohen’s kappa
coefficient (κ) as a measure of inter-observer agreement. A third researcher was involved to
solve disagreements in each stage (CMCP).
Inclusion criteria: (i) original research studies published in English; (ii) evaluation
of E-cad expression in human primary OSCC tissue by IHC; (iii) E-cad overexpression
association analysis including E-cad with at least one long-term outcome: overall survival
(OS), disease-free survival (DFS), or disease-specific survival (DSS). Lacking standardization
in survival endpoints nomenclature, studies evaluating the above-mentioned terms or
related terms that match these definitions (e.g., progression-free survival) were included in
each endpoint category.
Exclusion criteria: (i) reviews, meta-analysis, case reports, clinical trials, and editorials;
(ii) in vitro or animal-based studies; (iii) genomic-based research; (iv) studies that do
not deal with the relationship between E-cad expression and time-dependent outcomes;
(v) or in which presented data are insufficient to estimate Hazard Ratios; (vi) studies with
duplicated cohorts.

2.3. Data Extraction

The first author’s name, the year of publication, and the country and continent where
the study was conducted were included in the data extraction sheet. This information was
matched with the total number of patients included; edition for staging OSCC; recruitment
period; tumor subsite localization in the oral cavity; treatment modality; follow-up period;
cut-off value for E-cad IHC positivity and if there was a nuclear or cytoplasmic immunos-
taining pattern; hazard ratios (HRs) for long-term outcomes and covariates for multivariate
analysis (i.e., Cox regression models).

2.4. Quality Assessment

Included studies underwent a risk of bias assessment and checked for items included
in the Reporting Recommendations for Tumor Marker Prognostic Studies (REMARK)
guidelines [28]. Each evaluated item and criteria are already previously reported and
explained [29]. APJ and MPS independently scored all the included studies. Again, in
Biology 2023, 12, 239 5 of 18

case of disagreements, a third reviewer participated (AILP) until a consensus was reached.
Studies with an overall score >4 were considered at a low risk of bias.

2.5. Statistical Analysis

Based on the original papers’ cut-off, patients were categorized as having high or low
levels of E-cad expression. To estimate the impact of E-cad expression on time-dependent
outcomes, such as OS, DSS, and DFS, HRs and 95% confidential intervals (CIs) from both
univariate and multivariate analyses were used. For each study, we used the estimate that
was adjusted for the largest number of variables. In case HRs were not reported in the
original manuscript, their values were extracted from Kaplan–Meier curves as described by
Parmar et al. [30] and Tierney et al. [31] using Engauge Digitizer 4.1 (open-source digitizing
software developed by M. Mitchell). The corresponding or first authors were also emailed
when it was not possible to estimate the HRs as described above.
Weighted adjusted log HRs by the inverse of their variance were pooled in the meta-
analysis to calculate a pooled HR and its 95% CIs. Pooled analysis was performed using
both the fixed-effect method and random-effects models. The estimates considered as
most appropriate figures were selected based on between-study heterogeneity. Forest plots
were created to graphically represent the pooled analysis. A subgroup analysis based on
several variables was planned (i.e., tumor subsite, quality score, E-cad antibody, ethnic
variations, type of covariate adjustment, and cut-off point) to further explore the origin of
heterogeneity. The statistical significance was fixed at α = 0.05.
The Cochran’s Q statistic test, which is based on I2 statistics and the Chi-squared test,
was used to evaluate heterogeneity. For the Cochran’s Q test, heterogeneity was deemed
significant if I2 was greater than 50% or if there was a p-value of less than 0.10 [32]. Statis-
tical analyses were performed using the Open Meta-Analyst v.10 software and Metaanal
macro for SAS Statistics 9.4M7 software for Windows (SAS Ins., Rayleigh, NC, USA)
available at https://www.hsph.harvard.edu/donna-spiegelman/software/ accessed on
8 September 2022.

3. Results
3.1. Process of Study Selection and Features
The search strategy resulted in a total of 197 records. Abstract and title screening led
to the inclusion, in the first phase, of 65 studies. As a result of the second stage, full-text
reading led to the exclusion of 40 studies; in the end, 25 studies were included (Figure 2).
Excellent agreement between reviewers was shown by a κ-statistic value of 0.87. A total
of 2553 patients was included in the final meta-analysis of the 25 articles included in this
systematic review [6,33–57]. The collected descriptive characteristics of the chronologically
included studies are summarized in Table 1.
Excellent agreement between reviewers was shown by a κ-statistic value of 0.87. A total
of 2553 patients was included in the final meta-analysis of the 25 articles included in this
systematic review [6,33–57]. The collected descriptive characteristics of the chronologically
included studies are summarized in Table 1.

3.2. Quality Assessment

Six studies met all REMARK requirements in full. Setting a cut-off point score of >4,
12 studies were considered as low risk of bias, despite 13 studies not fulfilling the REMARK
items and these were considered as high risk of bias, as displayed in Table 3. Moderate
biases regarding “clinical data” and “immunohistochemistry” domains were evident in
some studies because of lacking inclusion criteria information, assessment methodology of
E-cad, and study settings. Regarding the “statistics” domain, several studies reported a
remarkable risk of biases for inappropriate statistics, erroneous/dubious data reporting, or
the absence of appropriate adjustment for confounding factors.
 The search strategy resulted in a total of 197 records. Abstract and title sc
to the inclusion, in the first phase, of 65 studies. As a result of the second sta
reading led to the exclusion of 40 studies; in the end, 25 studies were included

Biology 2023, 12, 239 6 of 18

Figure 2. PRISMA 2020 flow diagram.

Figure 2. PRISMA 2020 flow diagram.

Excellent agreement between reviewers was shown by a κ‐statistic valu

total of 2553 patients was included in the final meta‐analysis of the 25 articles
this systematic review [6,33–57]. The collected descriptive characteristics of t
logically included studies are summarized in Table 1.
Biology 2023, 12, 239 7 of 18

Table 1. General characteristics of included studies.

Recruitment Follow-Up E-Cadherin E-Cadherin (+)

Study Year Country Sample Size Tumor Subsite Cut-Off Point (%)
Period (Months) Antibody Cases
H5250
Chang et al. 2002 China 109 Tongue N/A 63 50 18
(monoclonal)
Clone 36
Lim et al. 2004 Japan 56 Tongue 1992–2000 24 50 18
(monoclonal)
HECD-1
Nakanishi et al. 2004 Japan 91 Tongue 1983–1995 58 80 28
(monoclonal)
Clone 36
Munoz-Guerra et al. 2005 Spain 50 Tongue, floor of mouth 1987–2000 36 NA 28
(monoclonal)
Tongue, floor of mouth, alveolar
Clone 36
Diniz-freitas et al. 2006 Spain 47 ridge, retromolar trigone, palate, 1995–2000 36 10 33
(monoclonal)
buccal mucosa
Tongue, floor of the mouth, sc-8426
Hung et al. 2006 Taiwan 45 1999–2005 29 10 19
gingiva, palate (monoclonal)
Clone 36
Ueda et al. 2006 Japan 135 NA 1990–1999 68 90 54
(monoclonal)
Tongue, floor of the mouth,
Clone 36
Kitaraha et al. 2007 Japan 80 gingiva, buccal mucosa, 1990–2005 NA 70 34
(monoclonal)
palate, lip
HECD-1
Pyo et al. 2007 USA 49 NA 1992–1999 NA 75 10
(monoclonal)
NCH-38
Forischini et al. 2008 Italy 58 NA N/A 19.7 50 20
(monoclonal)
Tongue, gingiva, floor of the
Wang et al. 2009 China 52 1994–2001 38.8 589 (monoclonal) 11 30
mouth, buccal mucosa, palate
Tongue, gingiva, floor of the ZM-0092
Liu et al. 2010 China 83 1994–2004 50.1 80 31
mouth, buccal mucosa, palate, lip (monoclonal)
Clone 36
Wang et al. 2011 China 230 Tongue 1996–2005 65 90 30
(monoclonal)
Tongue, floor of the mouth floor, Clone 36
Imajyo et al. 2012 Japan 152 1993–2006 NA NA 104
buccal mucosa, gingival (monoclonal)
Biology 2023, 12, 239 8 of 18

Table 1. Cont.

Recruitment Follow-Up E-Cadherin E-Cadherin (+)

Study Year Country Sample Size Tumor Subsite Cut-Off Point (%)
Period (Months) Antibody Cases
Tongue, floor of the mouth,
HECD-1
Rosado et al. 2012 Spain 59 gingiva, buccal mucosa, 1990–1992 55 67 37
(monoclonal)
palate, lip
sc-8426
Wang et al. 2012 China 76 Tongue 1996–2005 65 50 34
(monoclonal)
Tongue, floor of the mouth floor, sc-8426
Zhao et al. 2012 China 98 2001–2003 60 40 49
buccal mucosa, gingival (monoclonal)
Tongue, floor of the mouth, lip,
gingiva, hard palate, soft palate, sc-8426
Kaur et al. 2013 India 105 2002–2005 24 50 61
retromolar trigone and floor of (monoclonal)
the mouth
sc-8426
Wang et al. 2013 China 67 Tongue 1996–2005 65 50 27
(monoclonal)
Oral mucosa, Buccal, Gingival, NCH-38
Fan et al. 2014 Taiwan 74 1999–2006 NA 50 22
palate, Other (monoclonal)
Tongue, floor of the mouth,
Clone 36
Pannone et al. 2014 Italy 164 buccal mucosa, retromolar 1990–2006 39,41 NA 152
(monoclonal)
trigone, gingiva, palate, lip
NCH-38
Da Silva et al. 2015 Brazil 102 NA N/A 120 5 68
(monoclonal)
Ab40772
Ozaki-Honda et al 2017 Japan 76 NA 1983–2002 NA 50 55
(monoclonal)
M3612
Sgaramella et al. 2018 Sweden 120 Tongue N/A 47 20 118
(monoclonal)
The Nether- Tongue, floor of mouth, NCH-38
De Herdt et al 2020 203 1984–2010 NA 50 NA
lands gingiva, palate (monoclonal)
Tongue, Floor of the mouth, NCH-38
Wangmo et al. 2020 Thailand 200 2008–2011 NA 60 172
gingiva, buccal mucosa (monoclonal)
Biology 2023, 12, 239 9 of 18

Table 2. Data synthesis for pooled analysis and adjustments for each included study.

Disease-Free
Disease-Specific Survival
Study Year Overall Survival (HR 95% CI) Survival/Progression Free Adjustment
(HR 95% CI)
Survival (HR 95% CI)
Cox multivariate regression adjusted for gender, grade, TNM stage,
Chang et al. 2002 0.40 (0.17–0.94)
T stage and N status.
Lim et al. 2004 0.41 (0.20–0.84) Cox multivariate regression adjusted for stage, location, and N status.
Cox multivariate regression adjusted for age, gender, tumor
Nakanishi et al. 2004 0.22 (0.05–0.97) differentiation, N status, TNM stage, growth pattern, invasion depth,
and vessel invasion.
Munoz-Guerra et al. 2005 0.28 (0.09–0.87) Univariate.
Cox multivariate regression adjusted for stage and surgical
Diniz-freitas et al. 2006 0.18 (0.07–0.46) 0.41 (0.18–0.93)
margin status.
Hung et al. 2006 0.56 (0.23–1.36) Univariate.
Cox multivariate regression adjusted for tumor differentiation, T status,
Ueda et al. 2006 0.71 (0.19–2.65)
N status, TNM stage, and mode of invasion.
Kitaraha et al. 2007 0.36 (0.08–1.60) Univariate.
Cox multivariate regression adjusted for tumor differentiation, T status,
Pyo et al. 2007 0.77 (0.48–1.24)
N status, TNM stage, and mode of invasion.
Foschini et al. 2008 0.11 (0.02–0.61) Univariate.
Wang et al. 2009 0.28 (0.08–0.98) Univariate.
Liu et al. 2010 0.55 (0.37–0.82) Univariate.
Wang et al. 2011 0.15 (0.06–0.40) Univariate.
Imajyo et al. 2012 0.38 (0.12–1.20) 0.51 (0.29–0.98) Univariate.
Cox multivariate regression adjusted for TNM stage, T stage and
Rosado et al. 2012 0.56 (0.34–0.92)
N status.
Wang et al. 2012 0.78 (0.64–1.09) Univariate.
Zhao et al. 2012 0.42 (0.22–0.75) 0.74 (0.42–1.30) Cox multivariate regression adjusted for TNM stage and N status.
Kaur et al. 2013 0.26 (0.10–0.68) Univariate.
Wang et al. 2013 0.15 (0.05–0.45) Univariate.
Cox multivariate regression adjusted for betel quid chewing, cigarette
Fan et al. 2014 0.41 (0.22–0.75)
smoking, tumor size, TNM stage, and recurrence.
Biology 2023, 12, 239 10 of 18

Table 2. Cont.

Disease-Free
Disease-Specific Survival
Study Year Overall Survival (HR 95% CI) Survival/Progression Free Adjustment
(HR 95% CI)
Survival (HR 95% CI)
Pannone et al. 2014 0.43 (0.13–1.42) Univariate.
Da Silva et al. 2015 0.48 (0.23–1.00) Univariate.
Ozaki-Honda et al 2017 0.83 (0.20–3.48) Univariate.
Sgaramella et al. 2018 0.45 (0.23–0.80) Univariate.
De Herdt et al 2020 0.39 (0.21–0.72) 0.47 (0.28–0.79) Univariate.
Cox multivariate regression adjusted for T stage, N status, clinical
Wangmo et al. 2020 0.57 (0.34–0.96)
stage and treatment.

Table 3. Risk of bias assessment of included studies based on REMARK evaluation items.

Study Year Samples Clinical Data Immunohistochemistry Prognostication Statistics Classical Prognostic Factors Overall
Chang et al. 2002 I I I A A A 3
Lim et al. 2004 A A I A A A 5
Nakanishi et al. 2004 A A A A A A 6
Munoz-Guerra et al. 2005 A I A I I A 3
Diniz-freitas et al. 2006 A A A A A A 6
Hung et al. 2006 A A A A I I 4
Ueda et al. 2006 A A A A A A 6
Kitaraha et al. 2007 A A A A I A 5
Pyo et al. 2007 A I A I A A 5
Foschini et al. 2008 A I I I I I 1
Wang et al. 2009 A A I I I I 2
Biology 2023, 12, 239 11 of 18

Table 3. Cont.

Study Year Samples Clinical Data Immunohistochemistry Prognostication Statistics Classical Prognostic Factors Overall
Liu et al. 2010 I A I A I I 2
Wang et al. 2011 A A I A I I 3
Imajyo et al. 2012 A A A A I A 5
Rosado et al. 2012 A I A I A A 4
Wang et al. 2012 A I I A I A 3
Zhao et al. 2012 A A A A A A 6
Kaur et al. 2013 I I I I I A 1
Wang et al. 2013 A I A A I A 4
Fan et al. 2014 A A A A A A 6
Pannone et al. 2014 A A A A I I 4
Da Silva et al. 2015 A A A A I A 5
Ozaki-Honda et al 2017 A I I I I I 1
Sgaramella et al. 2018 I A A I I I 2
De Herdt et al 2020 A A A A I A 5
Wang Mo et al. 2020 A A A A A A 6
Biology 2023, 12, 239 12 of 18

3.3. Quantitative Evaluation (Meta-Analysis)

Based on the presence or absence of significant heterogeneity as indicated by the
p-values from their respective Q tests, the fixed-effect or random-effect models were used
to calculate the pooled HR with 95% CI for OS, DSS, and DFS (Figure 3). Although
there was some heterogeneity (I2 = 59.53%), the random-effects pooled HR value (95% CI)
of OS associated with E-cad IHC expression in the tissue of OSCC patients was 0.41
(95% CI 0.32–0.54; p < 0.001). Additionally, the DFS fixed-effects pooled HR value was 0.47
(95% CI 0.37–0.61; p < 0.001); I2 = 0% indicated that there was very little study-to-study
heterogeneity (Figure 3B). A fixed-effect meta-analysis of the DSS data revealed a HR of
Biology 2023, 12, x FOR PEER REVIEW
0.55 (95% CI 0.39–0.76; p < 0.001) and no between-study heterogeneity (I2 = 0%). Patients
with higher E-cad protein expression improved their long-term outcomes, relating to a
higher probability of survival and a decreased risk of relapsing the disease.

Figure 3. (A) Forest plots of overall survival and (B) disease-free survival. Horizontal axis represents
Hazard Ratios.

Table 4 collects the subgroup analysis for all of the 25 studies included in the meta-
analysis and 3.
Figure their
(A) pooled effectofestimates.
Forest plots The statistically
overall survival significant
and (B) disease‐free difference
survival. was axis r
Horizontal
preserved among
Hazard all subgroups, regarding the OS analysis. Of interest, lower pooled HR
Ratios.
emerged in the tongue subgroup (HR = 0.28, 95% CI 0.19–0.43; p < 0.001), in comparison
with the mixed
Table subsites. Similarly,
4. Subgroups the investigation
pooled hazard of the
ratios and 95% C36 antibody
confidence resulted
intervals in a
for long‐term outc
decreased HR (HR = 0.29, 95% CI 0.19–0.43; p < 0.001). The statistically significant difference
was also preserved for DFS, in all the subgroups; the use of other antibodies rather than
Number Pooled HR (95%
clone 35 was considered as Pooled
a sourceHR heterogeneity (I2 = 15.18).
of (95% QT
of Studies CI), Random Ef‐ p Value I2 (%)
CI), Fixed Effects V
(n) fects

Overall sur‐
vival

Overall 18 0.78 (0.74–0.83) 0.41 (0.32–0.54) <0.001 59.52 <0

High qual‐
9 0.45 (0.35–0.57) 0.43 (0.32–0.57) <0.001 20.30 0
ity

Low quality 9 0.80 (0.76–0.85) 0.51 (0.37–0.69) <0.001 77.61 <0

Biology 2023, 12, 239 13 of 18

Table 4. Subgroups pooled hazard ratios and 95% confidence intervals for long-term outcomes.

Pooled HR
Number of Pooled HR (95% CI),
(95% CI), p Value I2 (%) Q Test p Value
Studies (n) Random Effects
Fixed Effects
Overall
survival
Overall 18 0.78 (0.74–0.83) 0.41 (0.32–0.54) <0.001 59.52 <0.001
High quality 9 0.45 (0.35–0.57) 0.43 (0.32–0.57) <0.001 20.30 0.26
Low quality 9 0.80 (0.76–0.85) 0.51 (0.37–0.69) <0.001 77.61 <0.001
Full adjustment 6 0.47 (0.35–0.62) 0.42 (0.28–0.63) <0.001 47.94 0.09
Asian 12 0.80 (0.75–0.84) 0.48 (0.37–0.63) <0.001 75.27 <0.001
Non-Asian 6 0.47 (0.35–0.64) 0.39 (0.24–0.65) <0.001 55.87 <0.001
Tongue 5 0.28 (0.19–0.43) 0.28 (0.17–0.45) <0.001 29.34 0.23
Mixed subsites 13 0.79 (0.75–0.84) 0.55 (0.43–0.69) <0.001 68.03 <0.001
Use of Clone 36 antibody 5 0.29 (0.19–0.43) 0.29 (0.19–0.43) <0.001 0 0.47
Use of other antibodies 13 0.79 (0.75–0.84) 0.54 (0.43–0.69) <0.001 71.24 <0.001
Use of 50% cut-off point 7 0.81 (0.76–0.85) 0.52 (0.38–0.72) <0.001 78.96 <0.001
Use of other cut-off points 11 0.47 (0.38–0.58) 0.42 (0.31–0.57) <0.001 38.60 0.09
Disease-free
survival
Overall 9 0.47 (0.37–0.61) 0.47 (0.37–0.61) <0.001 0 0.64
High quality 5 0.54 (0.41–0.72) 0.54 (0.41–0.72) <0.001 0 0.72
Low quality 4 0.31 (0.19–0.52) 0.31 (0.19–0.52) 0.004 0 0.91
Full adjustment 4 0.55 (0.39–0.76) 0.55 (0.39–0.76) <0.001 0 0.68
Use of Clone 36 antibody 4 0.46 (0.31–0.69) 0.46 (0.31–0.69) <0.001 0 0.72
Use of other antibodies 5 0.48 (0.36–0.66) 0.47 (0.33–0.67) <0.001 15.18 0.32
Disease-
specific
survival
Overall 3 0.55 (0.39–0.76) 0.55 (0.39–0.76) <0.001 0 0.92

4. Discussion
In the present study, we show that tissue E-cad expression can serve as a prognostic
biomarker in OSCC, both for OS HR = 0.41 (95% CI 0.32–0.54; p < 0.001) and DFS HR = 0.47
(95% CI 0.37–0.61; p < 0.001)
Intercellular adhesion plays a major structural role in epithelial integrity and impair-
ment of cohesion between cells, and the altered expression of adhesion molecules in OSCC
determines an invasive behavior [58,59]. E-cad is associated with EMT in oral carcinogene-
sis and this feature strongly defines the prognosis of this neoplasm. The ability to invade
adjacent tissues and metastasize locoregionally is one of the most common clinical features
in OSCC [40,60]. Multiple cellular events, including changes in the cytoskeleton, matrix
protein proteolysis, disruption of cell-to-cell adhesive contacts, and migration, are required
for invasion and metastasis processes to occur [20,21]. Crucial for the metastatic ability
of cancer are a series of biomolecular changes and events, starting with the intercellular
adhesion dysfunctions. E-cad is an invasion suppressor molecule, which means that its
loss allows or increases the process of invasion of adjacent normal tissues, due to its role in
epithelial intercellular adhesion and in normal tissue morphogenesis [36,42]. In our study,
it was demonstrated that low E-cad expression is involved in worse OS, DFS, and DSS in pa-
tients with OSCC. Particularly, the HR value of OS was 0.41 with a moderate heterogeneity
rate (I2 = 59.53%) and in DFS, of 0.47 and in DSS, of 0.55, both with negligible heterogeneity.
The prognosis of OSCC depends on several factors such as tumor size, degree of
differentiation, and stage of disease [38]. Involvement of lymphatic metastasis is present
Biology 2023, 12, 239 14 of 18

in 30–40% of cases, being one of the main prognostic markers used in the clinic [55].
However, extensive local invasion and/or lymph node metastases are often present at the
initial diagnosis, resulting in a more unpredictable prognosis for this type of tumor and
consequently, raising doubts about the reliability of these clinical prognostic markers at
the time of diagnosis [53]. The primary OSCC that harbors metastases also carries genetic
alterations that favor this entire metastatic process, thus being a possible genetic portrait in
the prediction of OSCC cases with a high probability of leading to early metastases [47].
Currently, treatment decisions for OSCC are managed through clinicopathological
factors such as age, race, sex, histological grade, and tumor/nodule metastasis stage. Ob-
viously, all these factors are valid, but they do not provide accurate information about
the general aggressiveness of the tumor and its recurrence potential, demonstrating the
importance of indagating new methods to increase the reliability of treatment determina-
tion. Therefore, a series of biomarkers are being identified and studied to provide more
accurate prognostic information about OSSC, thereby facilitating the management of the
neoplasm [40]. A greater understanding about the molecular aspects of OSCC development
and progression is needed and the discovery of new targets is of utmost importance [54].
The unfavorable prognosis associated with the low expression of E-cad may be a
clinically reliable tumor biomarker together with other clinicopathological variables in the
decision of the treatment to be used in patients affected by this disease, such as a greater
margin of surgical intervention or a combination with radiotherapy/chemotherapy [33].
The upregulation of E-cad may also serve as a new antitumor target strategy, where a
stimulation of these cells would occur in order that through increased E-cad expression, a
change to a benign behavior in these tumor cells could occur [44].
From this point of view, the investigation of the distribution of cadherins and the
consequent behavior of tumors related to this expression is a very promising area of
interest, as they are biological markers that are cornerstones in predicting the outcome
of treatment [47]. Cell adhesion molecules in general, to which cadherins and catenins
belong, have a crucial role described in the literature—not only in cell-cell unions but also
in cell-extracellular matrix unions. E-cad is the main cadherin of epithelial cells and its
role in adherent junctions is responsible for establishing cell–cell contacts [38]. Loss of
heterozygosity and inactivating gene mutations, epigenetic silencing at the cancer site,
transcriptional repression, cadherin replacement, endocytosis, and proteolytic processing
are some of the mechanisms correlated with E-cad inhibition [52].
E-cad has its mechanism of action related to anchoring to the cytoskeleton via β-
catenin, which is a cytoplasmic plaque protein responsible for maintaining cell–cell ad-
hesion in normal oral squamous epithelium [58]. Interestingly, the loss of membranous
E-cad/β-catenin has been commonly associated with OSCC aggressive behavior through
increased tumor invasion, nodal metastasis, and an advanced clinical stage. Multivariate
logistic regression analyses demonstrated a loss of membranous expression of E-cad, being
the most significant phenotype associated with malignancy, leading to the finding that loss
of membranous E-cad/β-catenin are hallmarks of EMT [57]. The EMT process includes, in
addition to low intercellular adhesion, the loss of polarity of epithelial cells and increased
cell motility, playing a vital role in the progression of cancer [35,54]. This event requires
the coordinated expression of several sets of genes and signaling pathways [50]. In EMT,
E-cad is suppressed by the expression of Snail, the transcriptional repressor of E-cad, and
carcinoma cells that comprise tumor buds end up losing their contact and becoming cel-
lularized [45]. It is likely that several EMT patterns in tumor tissue serve as predictive
biomarkers for OSCC progression, which requires further studies, given that OSCC is a
pathological entity that remains poorly defined at the molecular level [46,57].
While this systematic review is not the first to be conducted on this topic, previous
reviews had several drawbacks. This current meta-analysis is superior as it maintains a
precise focus on the expression of E-cad in OSCC, without excluding groups and faithfully
considering the correlation of OS, DFS, and DSS with the expression of E-cad. Our study
Biology 2023, 12, 239 15 of 18

may be more reliable due to lower heterogeneity across studies and the accumulation of
studies with a low risk of bias.
Despite the interesting associations that emerged from this systematic review and
meta-analysis, results should be read with caution, and they are not free from limitations.
Some authors have mentioned the presence of molecular heterogeneities of tumor cells
in relation to different tumor locations (e.g., center/superficial portions, invasive tumor
fronts) [36,42]. The analysis of the EMT-generated tumor cell buds was performed by one
of the authors, who described that positive signals in the nucleus of these tumor buds can
impact the accuracy of E-cad expression assessments, which could be one of the reasons for
the discrepancies in previous studies [49].
Another possible limitation concerns the fact that some studies used different antibod-
ies and different methods (cut-off scoring) to assess staining within the same sample, which
is known to affect the results. E-cad levels have also been reported to vary among patients
based on ethno-geographical distribution, which could contribute in the inconsistent re-
sults shared among studies conducted in different parts of the world [49]. The anatomical
location of the tumors was also mentioned as an intervening variable. Differences of distri-
bution/staining of E-cad expression exist according to the site of the primary tumor, which
in the case of OSCC, is predominant as membrane staining. This is especially particular,
since the larynx usually exhibits both membrane and cytoplasmatic staining, while in the
oropharynx, it is almost exclusively cytoplasmic [49]. There was an overall consistency
with previous data, although it should be borne in mind that our results showed a stronger
biomarker performance for E-cad under the features outlined in our subgroup analysis.

5. Conclusions
E-cad appears to be a potential indicator of increased invasiveness and tumor metas-
tasis associated with poor outcomes in OSCC. E-cad regulates complex mechanisms im-
pacting epithelial tumor cell differentiation and epithelial–mesenchymal transitions with
translational pathways, translating biomolecular events into clinical outcomes.
If used in conjunction with other clinical and histological indicators, the low expression
of E-cad may be a reliable clinically-useful tumor marker in the decision-making of the
treatment to be used in these patients with anti-E-cad regimens, which may support surgical
resections and improve patient survival. In addition, new antitumor therapeutic strategies
and drugs may arise from the upregulation of these classic cadherins, which could have
a huge impact on improving the prognosis for OSCC. Forthcoming studies with well-
designed inclusion criteria and larger sample sizes evaluating the association of low E-cad
expression are still needed to validate the use of this protein as a tumor marker in OSCC.

Author Contributions: Conceptualization, A.I.L.-P., F.F.-V.e.S., C.M.C.-P., A.P.-J., M.G.O.-A., Ó.Á.-C.-I.

and V.C.A.C.; methodology, A.I.L.-P., F.F.-V.e.S., C.M.C.-P., A.P.-J., M.G.O.-A., V.C.A.C., M.P.-S., V.P.
and M.P.; software, A.I.L.-P. and F.F.-V.e.S.; validation V.P. and M.P.-S.; formal analysis A.I.L.-P. and
F.F.-V.e.S.; investigation, A.I.L.-P., F.F.-V.e.S., C.M.C.-P., A.P.-.J., M.G.O.-A. and Ó.Á.-C.-I.; resources
A.I.L.-P. and F.F.-V.e.S.; data curation F.F.-V.e.S. and M.P.-S.; writing—original draft preparation,
A.I.L.-P., F.F.-V.e.S., C.M.C.-P., A.P.-J., M.G.O.-A., Ó.Á.-C.-I. and V.C.A.C.; writing—review and
editing, M.P., V.P. and M.P.-S.; visualization, not applicable; supervision, V.P. and M.P.-S.; project
administration, V.P. and M.P.-S.; funding acquisition, V.P. All authors have read and agreed to the
published version of the manuscript.
Funding: Alba Pérez-Jardón is the recipient of a fellowship from the Fundación Instituto de Investi-
gación Sanitaria de Santiago de Compostela (FIDIS), grant number IDIS2020/PREDOC/03.
Institutional Review Board Statement: Not applicable for systematic review and meta-analysis design.
Informed Consent Statement: Not applicable.
Data Availability Statement: Data can be requested from the corresponding author upon justi-
fied query.
Conflicts of Interest: The authors declare no conflict of interest.
Biology 2023, 12, 239 16 of 18

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