A Study of Serum Beta 2-microglobulin (β2 M) and Lipid Bound Sialic Acid (Lsa) Levels in Oral Carcinoma Patients

A Study of Serum Beta 2-microglobulin (β2 M) and Lipid Bound Sialic Acid (Lsa) Levels in Oral Carcinoma Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Study of Serum Beta 2-microglobulin (β2 M) and Lipid Bound Sialic Acid (Lsa) Levels in Oral Carcinoma Patients Dr. Anurag Kapoor, Dr. Pradeep Sharma, Dr. Ajai Kumar, Dr. Kailash K Mittal, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5205822/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Oral cancer is a significant global health issue, and nearly one-third of cases are in India. The late-stage diagnosis common in India leads to poor survival outcomes, highlighting the need for early detection and effective biomarkers. Introduction: This study explored the potential of serum β2-microglobulin (β2 M) and lipid-bound sialic acid (LSA) as diagnostic and prognostic biomarkers for oral carcinoma, with a focus on the Indian population, where the disease burden is exceptionally high. Methodology: This case‒control study involved 200 participants (100 oral cancer patients and 100 healthy controls) aged > 20–60 years. Serum β2 M and LSA levels were measured using ELISA kits. All the statistical analyses, including ROC analysis and correlation studies, were performed using SPSS software to assess the diagnostic accuracy and clinical relevance of these biomarkers. Results: Serum β2 M and LSA levels were significantly greater in oral cancer patients than in controls, with β2 M showing near-perfect diagnostic accuracy (AUC 0.999) and LSA demonstrating excellent accuracy (AUC 0.945). Both biomarkers strongly correlated with advanced AJCC stages, underscoring their potential in assessing disease severity and aiding early detection. Conclusion: Serum β2 M and LSA levels are promising biomarkers for the diagnosis and assessment of oral carcinoma. Their incorporation into clinical practice could enhance early detection, prognosis, and treatment monitoring, ultimately improving patient outcomes. However, further research with larger cohorts is needed to validate these findings and explore their longitudinal applicability. Oncology Oral carcinoma β2-microglobulin (β2 M) lipid-bound sialic acid (LSA) biomarkers early detection prognosis Figures Figure 1 Figure 2 INTRODUCTION Oral cancer, a major global health concern, is defined as a malignancy that occurs in the oral cavity and includes the tongue, gums, lips, and mouth. According to the International Agency for Research on Cancer (IARC) and the World Health Organization (WHO), oral cancer encompasses a complex range of tumor pathologies that affect not only the oral cavity but also surrounding areas, such as the oropharynx and salivary glands [ 1 ]. It is recognized as the sixth most common cancer worldwide. However, in India, oral cancer represents an even more pressing issue, accounting for nearly one-third of global cases. Each year, India reports approximately 77,000 new cases and 52,000 deaths from this disease, making it a significant public health challenge [ 2 ]. The high prevalence of oral cancer in India is linked to various sociocultural factors, including the widespread use of tobacco in both smoked and smokeless forms, the consumption of areca nuts, and alcohol abuse. These risk factors, along with poor oral hygiene and dietary deficiencies, contribute to alarming incidence rates. Notably, a large percentage of oral cancer patients in India are diagnosed at advanced stages, leading to poor survival outcomes. According to the American Joint Committee on Cancer (AJCC), approximately 70% of oral cancer cases in India are diagnosed at stage III or IV, resulting in a five-year survival rate of merely 20% [ 2 ]. This finding contrasts sharply with that in the Western world, where early detection is more common and outcomes are generally better [ 3 ]. Given the high burden of disease and poor prognosis associated with late-stage diagnosis, early detection of oral cancer is crucial. Emerging biomarkers, such as beta-2 microglobulin (β2 M) and lipid-bound sialic acid (LSA), offer promising noninvasive diagnostic tools for the early detection and monitoring of oral cancer [ 4 , 5 , 6 ]. These biomarkers, which can be detected in serum or saliva, have shown potential in detecting oral cancer in its initial stages, thereby improving prognosis and reducing mortality [ 2 ]. Our study aimed to explore the significance of β2 M and LSA as diagnostic and prognostic markers in oral carcinoma, with a particular focus on the Indian population, where the disease burden is exceptionally high. By advancing our understanding of these biomarkers, we hope to contribute to the development of more effective screening protocols and targeted interventions that can mitigate the impact of oral cancer, especially among vulnerable and marginalized groups. MATERIALS & METHODS The study protocol was evaluated and approved by the Institutional Ethical Committee of UPUMS, Saifai, Etawah. Written informed consent was obtained from each participant after providing a detailed explanation of the study's nature. This research, conducted over one and a half years, was a case‒control study based in the Outpatient Department of Radiotherapy & Biochemistry at U.P. University of Medical Sciences, Saifai, Etawah. The study involved 200 subjects aged > 20–60 years who were divided into 100 healthy controls and 100 individuals diagnosed with various types of oral cancer. The sample size estimation was based on a 64.8% incidence of oral cancer in Central India [ 7 ], yielding a minimum required sample size of 92. Considering potential drop-outs, this number was rounded to 100 for each group. The inclusion criteria for patients included individuals clinically and histopathologically diagnosed with oral squamous cell carcinoma or leukoplakia with exposure to carcinogens but without oral lesions. The exclusion criteria included allergies, inflammatory reactions, systemic diseases, or other malignancies. Healthy controls were required to be free of oral lesions, other malignancies, and chronic conditions such as diabetes or cardiovascular diseases. Blood samples (5 ml) were collected under aseptic conditions and stored at -40°C until analysis. Serum β-2 microglobulin and lipid-bound sialic acid levels were measured using commercially available ELISA kits. For biochemical analysis, GENLISA™ ELISA kits from KRISHGEN BioSystems were used. The sandwich ELISA technique was used, where specific antibodies were precoated onto microwells. Samples and standards were added, followed by biotin-labeled antibodies and streptavidin-HRP to form a complex. After washing to remove nonspecific binding, a substrate solution (TMB) was added, and color development, proportional to the analyte concentration, was measured at 450 nm using a microplate reader. The detailed reagent preparation and assay procedures used were performed according to the kit manuals to ensure the accuracy and reliability of the results. STATISTICAL ANALYSIS: SPSS software (SPSS, Inc., Chicago, IL, USA) was used for statistical analysis with the Windows program (version 26.0). RESULTS The study analyzed the distributions of age, sex, chief complaints, habits, examination findings, serum β2 M concentration, and LSA score between the patients and controls. The age distribution revealed no significant difference (p = 0.2359), with 19% of the patients and 26% of the controls aged > 20–39 years and 81% of the patients and 74% of the controls aged 40–60 years. The sex distribution was also nonsignificant (p = 0.0914), with 6% of the patients and 13% of the controls being female and 94% of the patients and 87% of the controls being male ( Table 1 ) . Chief complaints, such as difficulty swallowing, neck swelling, and ulcers, were exclusively present in these patients, indicating a strong association with the condition (Fig. 1) . Table 1 Sociodemographic parameter distributions among the patients and controls Sociodemographic parameters CASE CONTROL P-VALUE N % N % AGE 20–39 19 19.00% 26 26.00% X = 1.405 p = 0.2359 40–60 81 81.00% 74 74.00% Grand Total 100 100.00% 100 100.00% SEX FEMALE 6 6.00% 13 13.00% X = 2.850 p = 0.0914 MALE 94 94.00% 87 87.00% Grand Total 100 100.00% 100 100.00% Habits such as alcoholism and smoking were significantly more prevalent in patients (57% and 72%, respectively) than in controls (12% and 15%, respectively), with p values < 0.0001 for both, suggesting a strong link between these habits and the condition ( Fig. 2 ) . Examination findings showed that patients had significantly lower Karnofsky Performance Status scores (60.4 ± 10.2) than did controls (90.5 ± 5.2), and 100% of patients exhibited poor oral hygiene, with a chi-square value of 117.5 and a p value < 0.0001. All patients were diagnosed with squamous cell carcinoma (SCC) according to notable tumor characteristics and detailed staging, including average tumor size (3.5 ± 1.2 cm), irregular margins (73%), and local/regional lymph node involvement (88%) ( Table 2 ) . Table 2 Examination findings among cases and controls Examination CASE CONTROL P-VALUE Karn of sky Performance Status 60.4 ± 10.2 90.5 ± 5.2 t = 26.29 p < 0.0001* Poor Oral Hygiene 100 26 X = 117.5 p < 0.0001* Tumor Type Squamous cell carcinoma - Tumor Size (cm) 3.5 ± 1.2 - Irregular Tumor Margins 73 - Involvement of surrounding areas 41 - Local/Regional lymph nodes 88 - Number 2.03 ± 1.17 - Size (cm) 2.38 ± 0.82 - Clinical stage as per AJCC 2018 - Stage II 62 - Stage III 30 - Stage IV 8 - Serum biomarker analysis demonstrated significantly greater mean LSA (1932.69 ± 2000.86) and β2 M (69.21 ± 50.81) LSA levels in patients than in controls (1182.73 ± 1112.77 for LSA and 1.46 ± 4.94 for β2 M), with p values of 0.0012 and < 0.0001, respectively ( Table 3 ) . ROC analysis indicated near-perfect diagnostic accuracy for β2 M (AUC 0.999) and excellent accuracy for LSA (AUC 0.945), with β2 M showing a sensitivity of 97.87% and specificity of 100.00%, and LSA showing a sensitivity of 80.85% and specificity of 94.34% ( Table 4 ) . Correlation analysis demonstrated strong positive correlations of β2 M (r = 0.97, p = 0.006) and LSA (r = 0.86, p = 0.008) with AJCC stage, highlighting their potential as diagnostic markers ( Table 5 ) . These findings underscore the importance of β2 M and LSA levels in diagnosing conditions and distinguishing between cases and controls. Table 3 Serum β2 M and LSA Levels CASE CONTROL P-VALUE MEAN SD MEAN SD LSA 1932.69 2000.86 1182.73 1112.77 t = 3.276 p = 0.0012* β 2 M 69.21 50.81 1.46 4.94 t = 13.27 p < 0.0001* Table 4 ROC analysis of β2 M and LSA scores AUC 95% CI Optimal Cutoff Sensitivity Specificity β2 M Levels 0.999 0.994- 1.000 2714.20 97.87% 100.00% LSA Levels 0.945 0.900–0.990 2234.84 80.85% 94.34% Table 5 Pearson correlation coefficients for β2 M and LSA counts according to AJCC stage Marker r Value 95% CI p Value β2 M Levels 0.97 0.95–0.98 p = 0.006* LSA Levels 0.86 0.79–0.90 p = 0.008* DISCUSSION Neoplastic cells exhibit various genetic alterations, including gene rearrangements, amplifications, and mutations, which disrupt critical pathways controlling cell growth, survival, and metastasis. These alterations, when common in specific tumor types, can serve as biomarkers for detection and targeted therapy [ 8 , 9 ]. Diagnostic and prognostic biomarkers, such as serum β2-microglobulin (β2-M), play a crucial role in identifying individuals at risk, diagnosing early-stage cancers, guiding treatment decisions, and monitoring responses [ 10 ]. β2-M, a small protein component of the HLA antigen, is expressed on nearly all nucleated cells and can be detected in bodily fluids. Elevated serum levels of β2-M in cancer may result from increased cellular activity, membrane turnover, or altered HLA expression, potentially helping tumors evade immune detection. These characteristics suggest a correlation between β2-M levels and tumor burden and cellular turnover, highlighting its potential as a valuable tumor marker in oral carcinoma research [ 11 – 13 ]. Our study revealed no statistically significant associations between age groups (20–39 and 40–60 years) and the likelihood of being a case or control of oral carcinoma. While 19% of individuals aged > 20–39 years are cases, while 26% are controls, the prevalence of NAFLD shifts notably in the 40–60 years age group, with 81% of the patients and 74% of the controls. The chi-square test with X = 1.405 and a p value of 0.2359 underscores this lack of significance, indicating that older individuals are disproportionately more likely to be cases than younger individuals are. The Sequeira et al. [ 10 ] study involved 25 patients with OSCC aged 30–71 years, with a maximum incidence of 41–60 years and more commonly occurring in males, which is in accordance with the findings of various epidemiological studies of oral cancer performed in India [ 14 – 17 ]. The study highlights a notable difference in the prevalence of alcoholism and smoking between cases and controls. Specifically, 57% of the patients reported alcoholism, whereas 12% of the controls reported alcoholism; 72% of the patients were smokers, while 15% were controls. These substantial differences (alcoholism: p < 0.0001; smoking: p < 0.0001) underscore the robust association between these behaviors and the studied conditions. The findings suggest that individuals with alcoholism and smoking habits are significantly more likely to develop oral carcinoma than are those without these risk factors. Our study aligns with findings from Kulkarni et al. [ 18 ], who also reported a significant prevalence of alcoholism and smoking among oral carcinoma patients compared to controls. Kulkarni et al. reported that the primary harmful behavior observed in both groups was tobacco chewing, with prevalence rates of 83.33% in Group A and 73.33% in Group B [ 18 ]. Additionally, Kulkarni et al. noted tobacco chewing as a predominant habit among their subjects, reinforcing its role as a major risk factor for oral cancer, especially in male patients [ 18 ]. The distribution of chief complaints in our study highlights significant disparities between cases and controls. Among the patients, various symptoms were prominently observed: 65% experienced difficulty swallowing, 51% had neck swelling, 73% reported pain swallowing, 33% had difficulty with tongue protrusion, 40% had hoarseness of voice, 26% had respiratory distress, 55% had throat pain, 29% had earache, 61% had a sore throat, 35% had excessive salivation, 47% had trismus, 86% had ulcers, and 32% had bleeding. In contrast, none of these symptoms were reported in the controls. This stark contrast underscores the strong association between these symptoms and oral carcinoma, indicating their utility as critical indicators in clinical diagnosis and management. Furthermore, our study comprehensively compared examination findings between cases and controls and revealed substantial differences. Patients exhibited a significantly lower Karnofsky Performance Status score (60.4 ± 10.2) than did controls (90.5 ± 5.2), with a t value of 26.29 and a p value less than 0.0001, indicating a pronounced decline in functional status among patients. Poor oral hygiene was uniformly prevalent in cases (100%) versus controls (26%), with a chi-square statistic of 117.5 and a p value less than 0.0001, emphasizing a robust association with oral hygiene status. All patients were diagnosed with squamous cell carcinoma tumors, which were characterized by an average size of 3.5 ± 1.2 cm and irregular margins in 73% of the patients. Additionally, 41% of the patients showed involvement of surrounding areas, and 88% had local/regional lymph node engagement, with an average of 2.03 ± 1.17 lymph nodes affected and an average size of 2.38 ± 0.82 cm. According to the AJCC 2018 staging system, 62% of patients were classified as Stage II, 30% as Stage III, and 8% as Stage IV, indicating an advanced disease presentation compared to that of the controls. These findings collectively underscore the severe clinical profile and advanced stage of oral carcinoma among patients in our study compared to controls. Rajapakshe et al. [ 19 ] and Geum et al. [ 20 ] underscored the pivotal role of TNM stage in influencing the prognosis of OSCC patients. According to Suresh et al. [ 21 ], there was a notable decrease in overall survival (OS) rates with advancing stage (P < 0.001). Rogers et al. [ 22 ] reported a stark difference in 5-year OS between OSCC patients without cervical lymph node metastasis (87%) and those with metastasis (54%). Furthermore, the OS rates varied significantly across lymph node stages: 87% for N0, 68% for N1, and 40% for N2-3, as observed in Suresh et al.'s study [ 21 ]. These results reaffirm the significant prognostic impact of cervical lymph node stage in patients with OSCC (P < 0.001, log-rank test). Our study contrasts significantly with Pires et al.’s findings across several key parameters. Pires et al. [ 23 ] presented findings on various types of carcinoma: microinvasive carcinoma affects males and females equally, with a mean age of 67.2 years (SD ± 13.05). The mean duration of complaint was 18.4 months (SD ± 22.7), with leukoerythroplastic areas observed in 73.1% and ulcerated areas in 50% of the patients. The tumors predominantly affected the border of the tongue (56%) and lower lip (16%), with a mean size of 1.9 cm (SD ± 1.6). Most patients reported no tobacco use (52.6%) or alcohol use (53.3%). Verrucous carcinoma predominantly affected elderly females (mean age 73.2 years, SD ± 14.3), presenting with leukoerythroplastic (78%) and ulcerated (56%) areas. The tumors were located mainly on the alveolar mucosa/gingiva (44.4%) and buccal mucosa/buccal sulcus (33.3%), with a mean size of 3.8 cm (SD ± 1.3). Tobacco use was reported in 60% of the participants, but alcohol use was minimal (33.3%). Spindle cell carcinoma primarily affects male adults (mean age 57 years, SD ± 10.4), who present with ulcerated areas (80%) and various affected sites, including the border of the tongue (40%) and alveolar mucosa/gingiva (20%). The mean tumor size was 4.3 cm (SD ± 1.5), and all patients reported both tobacco and alcohol use. The nasaloid OSCC patients included a male with a 10 cm lesion on the buccal mucosa and a female with a 2.5 cm lesion on the border of the tongue, both of which presented as ulcerated and leukoerythroplinous. One patient reported tobacco use. Papillary OSCC was observed in a 64-year-old male on the buccal mucosa, presenting as a 5 cm ulcerated lesion in a patient who was not a tobacco or nonalcoholic user. These comprehensive findings underscore the severe clinical presentation and advanced stage of oral carcinoma among patients in our study, reflecting a more challenging disease profile than reported by Pires et al. [ 23 ]. Sequeira et al. [ 10 ] observed a significant association between serum β2-M levels and nodal status in their study, suggesting its potential as a predictive marker for nodal involvement, which is crucial for prognosis and postsurgical outcomes in patients with carcinoma. Similarly, our study revealed a progressive increase in the serum β2-M concentration across clinical stages of OSCC, with a notable increase observed in stage IV patients (44%). This pattern aligns with findings by Kadam et al. [ 24 ] and Wilma et al. [ 25 ], who reported higher β2-M levels in OSCC with combined endophytic and exophytic growth patterns than in those with purely endophytic or exophytic growth patterns. Elevated β2-M levels have been linked to various lymphoid malignancies, such as multiple myeloma and B-cell non-Hodgkin's lymphoma [ 26 – 29 ]. Additionally, studies such as those by Hagberg et al. [ 30 ], Chronowski et al. [ 31 ] and Constantinides et al. [ 32 ] have associated elevated β2-M levels with disease stage and prognosis in Hodgkin's disease, highlighting its prognostic relevance across different cancers. A comparison of biomarker levels between patients and controls revealed substantial differences. Specifically, LSA scores were significantly greater in patients (mean: 1932.69, SD: 2000.86) than in controls (mean: 1182.73, SD: 1112.77), with a t value of 3.276 and a p value of 0.0012. Similarly, β2 M levels were markedly greater in patients (mean: 69.21, SD: 50.81) than in controls (mean: 1.46, SD: 4.94), with a higher t value of 13.27 and a p value less than 0.0001, highlighting a stronger association. Our study, in comparison to that of Agrawal et al., highlights significant differences in biomarker levels between cases and controls. Agrawal et al. [ 33 ] reported that the serum β2-microglobulin concentration significantly differed across groups: 1.88 ± 0.82 µg/ml in controls, 2.23 ± 0.84 µg/ml in patients with oral leukoplakia, and 3.23 ± 0.96 µg/ml in patients with oral squamous cell carcinoma (OSCC). The increase in β2-microglobulin levels from controls to patients with OSCC was highly statistically significant (p < 0.001), and patients with OSCC showed a significant increase in the β2-microglobulin level compared to patients with oral leukoplakia (p 0.05). Additionally, β2-microglobulin levels were found to increase significantly with age in the control group. These results suggest that both LSA and β2 M are robust biomarkers for distinguishing between individuals with and without oral carcinoma, underscoring their potential diagnostic utility. The current study reveals robust diagnostic performance metrics for β2 M and LSA levels in oral carcinoma patients. β2 M exhibited exceptional diagnostic accuracy, with an AUC of 0.999 (95% CI: 0.994-1.000), an optimal cutoff of 2714.20, a sensitivity of 97.87%, and a specificity of 100.00%. This indicates a near-perfect ability to differentiate patients from controls with minimal misclassification. The LSA also showed excellent diagnostic performance, with an AUC of 0.945 (95% CI: 0.900–0.990), an optimal cutoff of 2234.84, a sensitivity of 80.85%, and a specificity of 94.34%, which was slightly less accurate than that of β2 M but still highly effective. Moreover, correlation analysis revealed a very strong positive correlation for β2 M (r = 0.97, 95% CI = 0.95–0.98, p = 0.006) and a strong positive correlation for LSA (r = 0.86, 95% CI = 0.79–0.90, p = 0.008) with the condition studied. These findings underscore the reliability of β2 M and LSA levels as diagnostic markers, with β2 M demonstrating a particularly robust correlation and diagnostic accuracy in oral carcinoma. Similarly, Viashali and Tupkari et al. similarly demonstrated a notable association between serum β2 M levels and the histological grade of SCC, suggesting that this biomarker is a sensitive tool for diagnosis, analysis, and prognosis [ 34 ]. This study highlights the potential of serum β2 M and LSA as diagnostic biomarkers for oral carcinoma. The marked increase in the expression of these biomarkers in patients, along with their strong correlations with advanced AJCC stages, underscores their clinical relevance in assessing disease severity. The high diagnostic accuracy of the β2 M and LSA, demonstrated by their AUC values and optimal cutoffs, suggest their effectiveness in distinguishing patients from controls with high sensitivity and specificity. Incorporating these biomarkers into clinical practice could improve early detection, patient prognosis, and treatment monitoring in oral carcinoma patients, ultimately enhancing patient outcomes. However, further research should validate these findings in larger cohorts and explore their longitudinal applicability to confirm their clinical utility. CONCLUSION This study demonstrated the significant utility of serum β2-microglobulin (β2 M) and lipid-bound sialic acid (LSA) levels as biomarkers for diagnosing and assessing the severity of oral carcinoma. Elevated levels of β2 M and LSA were strongly associated with the presence and progression of the disease, with β2 M showing particularly high diagnostic accuracy. Additionally, the analysis highlighted important demographic and clinical characteristics, such as the greater prevalence of cases in older age groups and the significant association of habits such as alcoholism and smoking with oral carcinoma. The study also emphasized the clinical impact of these interventions, with patients exhibiting lower Karnofsky Performance Status and poor oral hygiene. These findings underscore the importance of early detection and intervention, suggesting that β2 M and LSA levels could play a crucial role in improving patient management and outcomes. However, further research with larger cohorts is needed to validate the effectiveness of these biomarkers and explore their potential for long-term disease monitoring. Declarations CONFLICT OF INTEREST: The authors declare that there are no conflicts of interest. SOURCE OF FUNDING: The study received no external funding. CONSENT: Written informed consent was obtained from all participants in accordance with international or university standards and was obtained from the authors. ETHICAL APPROVAL: Ethical approval was granted in compliance with international or university standards, and written approval was obtained from the authors. 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Sharma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIiWNgGAWjYFCCA0BYwMDAxsx8AMiTkCFSiwEDAz87WwJICw+RNgG1SPbzGICYhLXwNx5+CLTFRs7gMM/nVzdqLHgY2A8f3YBPi8SBYwZALWnGBod5t1nnHAM6jCct7QZ+rxwAaTmcuAGoxTiHDahFgscMrxb5A8c/ALX8B2rheWac848ILQYHzoBsOZA4s5mH+XFuGxFaDA+cKTiQYJBszM/MZsac2yfBw0bIL3I3jm/+8KHCTo6N//Djzznf6uT42Q8fw+99iQMMDAkQJpsEmMSrHAT4G+BM5g8EVY+CUTAKRsGIBACNQEnFWW1EFwAAAABJRU5ErkJggg==","orcid":"","institution":"Uttar Pradesh University of Medical Sciences Saifai Etawah UP-206130","correspondingAuthor":true,"prefix":"Dr.","firstName":"Pradeep","middleName":"","lastName":"Sharma","suffix":""},{"id":367339328,"identity":"8bc3d3ee-c159-4d4e-b670-d22466044e29","order_by":2,"name":"Dr. Ajai Kumar","email":"","orcid":"","institution":"Uttar Pradesh University of Medical Sciences Saifai Etawah UP-206130","correspondingAuthor":false,"prefix":"Dr.","firstName":"Ajai","middleName":"","lastName":"Kumar","suffix":""},{"id":367322978,"identity":"f7985f9c-ed39-4f1f-a7dd-53cfffdaf7e3","order_by":3,"name":"Dr. Kailash K Mittal","email":"","orcid":"","institution":"Uttar Pradesh University of Medical Sciences Saifai Etawah UP-206130","correspondingAuthor":false,"prefix":"Dr.","firstName":"Kailash","middleName":"K","lastName":"Mittal","suffix":""},{"id":367322979,"identity":"a5b3bd9d-8fd1-4076-8d3d-0f3e79ba6228","order_by":4,"name":"Jitendra Pratap Singh Chauhan","email":"","orcid":"","institution":"Uttar Pradesh University of Medical Sciences Saifai Etawah UP-206130","correspondingAuthor":false,"prefix":"","firstName":"Jitendra","middleName":"Pratap Singh","lastName":"Chauhan","suffix":""},{"id":367322980,"identity":"6775a579-7e23-4fd4-beea-1b9124783e68","order_by":5,"name":"Dr. Nardev","email":"","orcid":"","institution":"Uttar Pradesh University of Medical Sciences Saifai Etawah UP-206130","correspondingAuthor":false,"prefix":"Dr.","firstName":"","middleName":"","lastName":"Nardev","suffix":""},{"id":367322982,"identity":"d4c358af-77a4-449f-96ee-88bfc46d20e3","order_by":6,"name":"Dr. Amit Kumar Singh","email":"","orcid":"","institution":"Uttar Pradesh University of Medical Sciences Saifai Etawah UP-206130","correspondingAuthor":false,"prefix":"Dr.","firstName":"Amit","middleName":"Kumar","lastName":"Singh","suffix":""},{"id":367322981,"identity":"d0adad5d-07fc-4c27-82b0-c779a6672023","order_by":7,"name":"Kumar Singh","email":"","orcid":"","institution":"Uttar Pradesh University of Medical Sciences Saifai Etawah UP-206130","correspondingAuthor":false,"prefix":"","firstName":"Kumar","middleName":"","lastName":"Singh","suffix":""}],"badges":[],"createdAt":"2024-10-04 19:10:11","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5205822/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5205822/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66326993,"identity":"12613aeb-2f21-43e3-a1e3-13797ad3d2cb","added_by":"auto","created_at":"2024-10-10 13:02:40","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62688,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraphical representations of chief complaints among cases and controls.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5205822/v1/571a7fd1c7d83f05662deef1.png"},{"id":66326349,"identity":"e56d06c0-e857-44c8-8b15-9662f0dafec7","added_by":"auto","created_at":"2024-10-10 12:54:40","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":29425,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraphical representations of habits among cases and controls\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5205822/v1/e383a13ed6d6795c7306eb43.png"},{"id":66980935,"identity":"602341cf-dce3-4e90-827e-66f91529a9be","added_by":"auto","created_at":"2024-10-18 17:30:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":624248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5205822/v1/60ec4406-d604-427b-8ea0-ed6eaaf7d00e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eA Study of Serum Beta 2-microglobulin (β2 M) and Lipid Bound Sialic Acid (Lsa) Levels in Oral Carcinoma Patients\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eOral cancer, a major global health concern, is defined as a malignancy that occurs in the oral cavity and includes the tongue, gums, lips, and mouth. According to the International Agency for Research on Cancer (IARC) and the World Health Organization (WHO), oral cancer encompasses a complex range of tumor pathologies that affect not only the oral cavity but also surrounding areas, such as the oropharynx and salivary glands [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is recognized as the sixth most common cancer worldwide. However, in India, oral cancer represents an even more pressing issue, accounting for nearly one-third of global cases. Each year, India reports approximately 77,000 new cases and 52,000 deaths from this disease, making it a significant public health challenge [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe high prevalence of oral cancer in India is linked to various sociocultural factors, including the widespread use of tobacco in both smoked and smokeless forms, the consumption of areca nuts, and alcohol abuse. These risk factors, along with poor oral hygiene and dietary deficiencies, contribute to alarming incidence rates. Notably, a large percentage of oral cancer patients in India are diagnosed at advanced stages, leading to poor survival outcomes. According to the American Joint Committee on Cancer (AJCC), approximately 70% of oral cancer cases in India are diagnosed at stage III or IV, resulting in a five-year survival rate of merely 20% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This finding contrasts sharply with that in the Western world, where early detection is more common and outcomes are generally better [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the high burden of disease and poor prognosis associated with late-stage diagnosis, early detection of oral cancer is crucial. Emerging biomarkers, such as beta-2 microglobulin (β2 M) and lipid-bound sialic acid (LSA), offer promising noninvasive diagnostic tools for the early detection and monitoring of oral cancer [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These biomarkers, which can be detected in serum or saliva, have shown potential in detecting oral cancer in its initial stages, thereby improving prognosis and reducing mortality [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Our study aimed to explore the significance of β2 M and LSA as diagnostic and prognostic markers in oral carcinoma, with a particular focus on the Indian population, where the disease burden is exceptionally high. By advancing our understanding of these biomarkers, we hope to contribute to the development of more effective screening protocols and targeted interventions that can mitigate the impact of oral cancer, especially among vulnerable and marginalized groups.\u003c/p\u003e"},{"header":"MATERIALS \u0026 METHODS","content":"\u003cp\u003eThe study protocol was evaluated and approved by the Institutional Ethical Committee of UPUMS, Saifai, Etawah. Written informed consent was obtained from each participant after providing a detailed explanation of the study's nature. This research, conducted over one and a half years, was a case‒control study based in the Outpatient Department of Radiotherapy \u0026amp; Biochemistry at U.P. University of Medical Sciences, Saifai, Etawah. The study involved 200 subjects aged\u0026thinsp;\u0026gt;\u0026thinsp;20\u0026ndash;60 years who were divided into 100 healthy controls and 100 individuals diagnosed with various types of oral cancer.\u003c/p\u003e \u003cp\u003eThe sample size estimation was based on a 64.8% incidence of oral cancer in Central India [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], yielding a minimum required sample size of 92. Considering potential drop-outs, this number was rounded to 100 for each group. The inclusion criteria for patients included individuals clinically and histopathologically diagnosed with oral squamous cell carcinoma or leukoplakia with exposure to carcinogens but without oral lesions. The exclusion criteria included allergies, inflammatory reactions, systemic diseases, or other malignancies. Healthy controls were required to be free of oral lesions, other malignancies, and chronic conditions such as diabetes or cardiovascular diseases.\u003c/p\u003e \u003cp\u003eBlood samples (5 ml) were collected under aseptic conditions and stored at -40\u0026deg;C until analysis. Serum β-2 microglobulin and lipid-bound sialic acid levels were measured using commercially available ELISA kits. For biochemical analysis, GENLISA\u0026trade; ELISA kits from KRISHGEN BioSystems were used. The sandwich ELISA technique was used, where specific antibodies were precoated onto microwells. Samples and standards were added, followed by biotin-labeled antibodies and streptavidin-HRP to form a complex. After washing to remove nonspecific binding, a substrate solution (TMB) was added, and color development, proportional to the analyte concentration, was measured at 450 nm using a microplate reader. The detailed reagent preparation and assay procedures used were performed according to the kit manuals to ensure the accuracy and reliability of the results.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTATISTICAL ANALYSIS:\u003c/h2\u003e \u003cp\u003eSPSS software (SPSS, Inc., Chicago, IL, USA) was used for statistical analysis with the Windows program (version 26.0).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe study analyzed the distributions of age, sex, chief complaints, habits, examination findings, serum β2 M concentration, and LSA score between the patients and controls. The age distribution revealed no significant difference (p\u0026thinsp;=\u0026thinsp;0.2359), with 19% of the patients and 26% of the controls aged\u0026thinsp;\u0026gt;\u0026thinsp;20\u0026ndash;39 years and 81% of the patients and 74% of the controls aged 40\u0026ndash;60 years. The sex distribution was also nonsignificant (p\u0026thinsp;=\u0026thinsp;0.0914), with 6% of the patients and 13% of the controls being female and 94% of the patients and 87% of the controls being male \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Chief complaints, such as difficulty swallowing, neck swelling, and ulcers, were exclusively present in these patients, indicating a strong association with the condition \u003cb\u003e(Fig.\u0026nbsp;1)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic parameter distributions among the patients and controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eSociodemographic parameters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eCASE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eCONTROL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-VALUE\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eN\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAGE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u0026thinsp;=\u0026thinsp;1.405\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.2359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e74.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrand Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.00%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e100.00%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSEX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFEMALE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u0026thinsp;=\u0026thinsp;2.850\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.0914\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMALE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrand Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e100.00%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e100\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e100.00%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHabits such as alcoholism and smoking were significantly more prevalent in patients (57% and 72%, respectively) than in controls (12% and 15%, respectively), with p values\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 for both, suggesting a strong link between these habits and the condition \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Examination findings showed that patients had significantly lower Karnofsky Performance Status scores (60.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2) than did controls (90.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2), and 100% of patients exhibited poor oral hygiene, with a chi-square value of 117.5 and a p value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001. All patients were diagnosed with squamous cell carcinoma (SCC) according to notable tumor characteristics and detailed staging, including average tumor size (3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 cm), irregular margins (73%), and local/regional lymph node involvement (88%) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExamination findings among cases and controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExamination\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCASE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCONTROL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-VALUE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKarn of sky Performance Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;26.29\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.0001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor Oral Hygiene\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eX\u0026thinsp;=\u0026thinsp;117.5\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.0001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor Size (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIrregular Tumor Margins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolvement of surrounding areas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal/Regional lymph nodes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSize (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical stage as per AJCC 2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSerum biomarker analysis demonstrated significantly greater mean LSA (1932.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2000.86) and β2 M (69.21\u0026thinsp;\u0026plusmn;\u0026thinsp;50.81) LSA levels in patients than in controls (1182.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1112.77 for LSA and 1.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.94 for β2 M), with p values of 0.0012 and \u0026lt;\u0026thinsp;0.0001, respectively \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. ROC analysis indicated near-perfect diagnostic accuracy for β2 M (AUC 0.999) and excellent accuracy for LSA (AUC 0.945), with β2 M showing a sensitivity of 97.87% and specificity of 100.00%, and LSA showing a sensitivity of 80.85% and specificity of 94.34% \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Correlation analysis demonstrated strong positive correlations of β2 M (r\u0026thinsp;=\u0026thinsp;0.97, p\u0026thinsp;=\u0026thinsp;0.006) and LSA (r\u0026thinsp;=\u0026thinsp;0.86, p\u0026thinsp;=\u0026thinsp;0.008) with AJCC stage, highlighting their potential as diagnostic markers \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. These findings underscore the importance of β2 M and LSA levels in diagnosing conditions and distinguishing between cases and controls.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSerum β2 M and LSA Levels\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCASE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eCONTROL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-VALUE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMEAN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eMEAN\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1932.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2000.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1182.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1112.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;3.276\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.0012*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eβ 2 M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;13.27\u003c/p\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.0001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eROC analysis of β2 M and LSA scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAUC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOptimal Cutoff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSensitivity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSpecificity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eβ2 M Levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.994- 1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2714.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e97.87%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e100.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLSA Levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.945\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.900\u0026ndash;0.990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2234.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80.85%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e94.34%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePearson correlation coefficients for β2 M and LSA counts according to AJCC stage\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarker\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003er Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eβ2 M Levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.95\u0026ndash;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.006*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLSA Levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.79\u0026ndash;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.008*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eNeoplastic cells exhibit various genetic alterations, including gene rearrangements, amplifications, and mutations, which disrupt critical pathways controlling cell growth, survival, and metastasis. These alterations, when common in specific tumor types, can serve as biomarkers for detection and targeted therapy [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Diagnostic and prognostic biomarkers, such as serum β2-microglobulin (β2-M), play a crucial role in identifying individuals at risk, diagnosing early-stage cancers, guiding treatment decisions, and monitoring responses [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. β2-M, a small protein component of the HLA antigen, is expressed on nearly all nucleated cells and can be detected in bodily fluids. Elevated serum levels of β2-M in cancer may result from increased cellular activity, membrane turnover, or altered HLA expression, potentially helping tumors evade immune detection. These characteristics suggest a correlation between β2-M levels and tumor burden and cellular turnover, highlighting its potential as a valuable tumor marker in oral carcinoma research [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study revealed no statistically significant associations between age groups (20\u0026ndash;39 and 40\u0026ndash;60 years) and the likelihood of being a case or control of oral carcinoma. While 19% of individuals aged\u0026thinsp;\u0026gt;\u0026thinsp;20\u0026ndash;39 years are cases, while 26% are controls, the prevalence of NAFLD shifts notably in the 40\u0026ndash;60 years age group, with 81% of the patients and 74% of the controls. The chi-square test with X\u0026thinsp;=\u0026thinsp;1.405 and a p value of 0.2359 underscores this lack of significance, indicating that older individuals are disproportionately more likely to be cases than younger individuals are. The \u003cb\u003eSequeira et al.\u003c/b\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] study involved 25 patients with OSCC aged 30\u0026ndash;71 years, with a maximum incidence of 41\u0026ndash;60 years and more commonly occurring in males, which is in accordance with the findings of various epidemiological studies of oral cancer performed in India [\u003cspan additionalcitationids=\"CR15 CR16\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study highlights a notable difference in the prevalence of alcoholism and smoking between cases and controls. Specifically, 57% of the patients reported alcoholism, whereas 12% of the controls reported alcoholism; 72% of the patients were smokers, while 15% were controls. These substantial differences (alcoholism: p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001; smoking: p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) underscore the robust association between these behaviors and the studied conditions. The findings suggest that individuals with alcoholism and smoking habits are significantly more likely to develop oral carcinoma than are those without these risk factors. Our study aligns with findings from \u003cb\u003eKulkarni et al.\u003c/b\u003e [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], who also reported a significant prevalence of alcoholism and smoking among oral carcinoma patients compared to controls. \u003cb\u003eKulkarni et al.\u003c/b\u003e reported that the primary harmful behavior observed in both groups was tobacco chewing, with prevalence rates of 83.33% in Group A and 73.33% in Group B [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Additionally, \u003cb\u003eKulkarni et al.\u003c/b\u003e noted tobacco chewing as a predominant habit among their subjects, reinforcing its role as a major risk factor for oral cancer, especially in male patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe distribution of chief complaints in our study highlights significant disparities between cases and controls. Among the patients, various symptoms were prominently observed: 65% experienced difficulty swallowing, 51% had neck swelling, 73% reported pain swallowing, 33% had difficulty with tongue protrusion, 40% had hoarseness of voice, 26% had respiratory distress, 55% had throat pain, 29% had earache, 61% had a sore throat, 35% had excessive salivation, 47% had trismus, 86% had ulcers, and 32% had bleeding. In contrast, none of these symptoms were reported in the controls. This stark contrast underscores the strong association between these symptoms and oral carcinoma, indicating their utility as critical indicators in clinical diagnosis and management. Furthermore, our study comprehensively compared examination findings between cases and controls and revealed substantial differences. Patients exhibited a significantly lower Karnofsky Performance Status score (60.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2) than did controls (90.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2), with a t value of 26.29 and a p value less than 0.0001, indicating a pronounced decline in functional status among patients. Poor oral hygiene was uniformly prevalent in cases (100%) versus controls (26%), with a chi-square statistic of 117.5 and a p value less than 0.0001, emphasizing a robust association with oral hygiene status. All patients were diagnosed with squamous cell carcinoma tumors, which were characterized by an average size of 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 cm and irregular margins in 73% of the patients. Additionally, 41% of the patients showed involvement of surrounding areas, and 88% had local/regional lymph node engagement, with an average of 2.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17 lymph nodes affected and an average size of 2.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82 cm. According to the AJCC 2018 staging system, 62% of patients were classified as Stage II, 30% as Stage III, and 8% as Stage IV, indicating an advanced disease presentation compared to that of the controls. These findings collectively underscore the severe clinical profile and advanced stage of oral carcinoma among patients in our study compared to controls. \u003cb\u003eRajapakshe et al.\u003c/b\u003e [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] \u003cb\u003eand Geum et al.\u003c/b\u003e [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] underscored the pivotal role of TNM stage in influencing the prognosis of OSCC patients. According to \u003cb\u003eSuresh et al.\u003c/b\u003e [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], there was a notable decrease in overall survival (OS) rates with advancing stage (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). \u003cb\u003eRogers et al.\u003c/b\u003e [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported a stark difference in 5-year OS between OSCC patients without cervical lymph node metastasis (87%) and those with metastasis (54%). Furthermore, the OS rates varied significantly across lymph node stages: 87% for N0, 68% for N1, and 40% for N2-3, as observed in \u003cb\u003eSuresh et al.'s\u003c/b\u003e study [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These results reaffirm the significant prognostic impact of cervical lymph node stage in patients with OSCC (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, log-rank test). Our study contrasts significantly with Pires et al.\u0026rsquo;s findings across several key parameters. \u003cb\u003ePires et al.\u003c/b\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] presented findings on various types of carcinoma: microinvasive carcinoma affects males and females equally, with a mean age of 67.2 years (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;13.05). The mean duration of complaint was 18.4 months (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;22.7), with leukoerythroplastic areas observed in 73.1% and ulcerated areas in 50% of the patients. The tumors predominantly affected the border of the tongue (56%) and lower lip (16%), with a mean size of 1.9 cm (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6). Most patients reported no tobacco use (52.6%) or alcohol use (53.3%). Verrucous carcinoma predominantly affected elderly females (mean age 73.2 years, SD\u0026thinsp;\u0026plusmn;\u0026thinsp;14.3), presenting with leukoerythroplastic (78%) and ulcerated (56%) areas. The tumors were located mainly on the alveolar mucosa/gingiva (44.4%) and buccal mucosa/buccal sulcus (33.3%), with a mean size of 3.8 cm (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3). Tobacco use was reported in 60% of the participants, but alcohol use was minimal (33.3%). Spindle cell carcinoma primarily affects male adults (mean age 57 years, SD\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4), who present with ulcerated areas (80%) and various affected sites, including the border of the tongue (40%) and alveolar mucosa/gingiva (20%). The mean tumor size was 4.3 cm (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5), and all patients reported both tobacco and alcohol use. The nasaloid OSCC patients included a male with a 10 cm lesion on the buccal mucosa and a female with a 2.5 cm lesion on the border of the tongue, both of which presented as ulcerated and leukoerythroplinous. One patient reported tobacco use. Papillary OSCC was observed in a 64-year-old male on the buccal mucosa, presenting as a 5 cm ulcerated lesion in a patient who was not a tobacco or nonalcoholic user. These comprehensive findings underscore the severe clinical presentation and advanced stage of oral carcinoma among patients in our study, reflecting a more challenging disease profile than reported by \u003cb\u003ePires et al.\u003c/b\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. \u003cb\u003eSequeira et al.\u003c/b\u003e [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] observed a significant association between serum β2-M levels and nodal status in their study, suggesting its potential as a predictive marker for nodal involvement, which is crucial for prognosis and postsurgical outcomes in patients with carcinoma. Similarly, our study revealed a progressive increase in the serum β2-M concentration across clinical stages of OSCC, with a notable increase observed in stage IV patients (44%). This pattern aligns with findings by \u003cb\u003eKadam et al.\u003c/b\u003e [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] \u003cb\u003eand Wilma et al.\u003c/b\u003e [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], who reported higher β2-M levels in OSCC with combined endophytic and exophytic growth patterns than in those with purely endophytic or exophytic growth patterns. Elevated β2-M levels have been linked to various lymphoid malignancies, such as multiple myeloma and B-cell non-Hodgkin's lymphoma [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Additionally, studies such as those by \u003cb\u003eHagberg et al.\u003c/b\u003e [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], \u003cb\u003eChronowski et al.\u003c/b\u003e [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and \u003cb\u003eConstantinides et al.\u003c/b\u003e [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] have associated elevated β2-M levels with disease stage and prognosis in Hodgkin's disease, highlighting its prognostic relevance across different cancers.\u003c/p\u003e \u003cp\u003eA comparison of biomarker levels between patients and controls revealed substantial differences. Specifically, LSA scores were significantly greater in patients (mean: 1932.69, SD: 2000.86) than in controls (mean: 1182.73, SD: 1112.77), with a t value of 3.276 and a p value of 0.0012. Similarly, β2 M levels were markedly greater in patients (mean: 69.21, SD: 50.81) than in controls (mean: 1.46, SD: 4.94), with a higher t value of 13.27 and a p value less than 0.0001, highlighting a stronger association. Our study, in comparison to that of Agrawal et al., highlights significant differences in biomarker levels between cases and controls. \u003cb\u003eAgrawal et al.\u003c/b\u003e [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] reported that the serum β2-microglobulin concentration significantly differed across groups: 1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82 \u0026micro;g/ml in controls, 2.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.84 \u0026micro;g/ml in patients with oral leukoplakia, and 3.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.96 \u0026micro;g/ml in patients with oral squamous cell carcinoma (OSCC). The increase in β2-microglobulin levels from controls to patients with OSCC was highly statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and patients with OSCC showed a significant increase in the β2-microglobulin level compared to patients with oral leukoplakia (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Although β2-microglobulin levels were greater in patients with oral leukoplakia than in controls, this difference was not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Additionally, β2-microglobulin levels were found to increase significantly with age in the control group. These results suggest that both LSA and β2 M are robust biomarkers for distinguishing between individuals with and without oral carcinoma, underscoring their potential diagnostic utility.\u003c/p\u003e \u003cp\u003eThe current study reveals robust diagnostic performance metrics for β2 M and LSA levels in oral carcinoma patients. β2 M exhibited exceptional diagnostic accuracy, with an AUC of 0.999 (95% CI: 0.994-1.000), an optimal cutoff of 2714.20, a sensitivity of 97.87%, and a specificity of 100.00%. This indicates a near-perfect ability to differentiate patients from controls with minimal misclassification. The LSA also showed excellent diagnostic performance, with an AUC of 0.945 (95% CI: 0.900\u0026ndash;0.990), an optimal cutoff of 2234.84, a sensitivity of 80.85%, and a specificity of 94.34%, which was slightly less accurate than that of β2 M but still highly effective. Moreover, correlation analysis revealed a very strong positive correlation for β2 M (r\u0026thinsp;=\u0026thinsp;0.97, 95% CI\u0026thinsp;=\u0026thinsp;0.95\u0026ndash;0.98, p\u0026thinsp;=\u0026thinsp;0.006) and a strong positive correlation for LSA (r\u0026thinsp;=\u0026thinsp;0.86, 95% CI\u0026thinsp;=\u0026thinsp;0.79\u0026ndash;0.90, p\u0026thinsp;=\u0026thinsp;0.008) with the condition studied. These findings underscore the reliability of β2 M and LSA levels as diagnostic markers, with β2 M demonstrating a particularly robust correlation and diagnostic accuracy in oral carcinoma. Similarly, \u003cb\u003eViashali and Tupkari et al.\u003c/b\u003e similarly demonstrated a notable association between serum β2 M levels and the histological grade of SCC, suggesting that this biomarker is a sensitive tool for diagnosis, analysis, and prognosis [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study highlights the potential of serum β2 M and LSA as diagnostic biomarkers for oral carcinoma. The marked increase in the expression of these biomarkers in patients, along with their strong correlations with advanced AJCC stages, underscores their clinical relevance in assessing disease severity. The high diagnostic accuracy of the β2 M and LSA, demonstrated by their AUC values and optimal cutoffs, suggest their effectiveness in distinguishing patients from controls with high sensitivity and specificity. Incorporating these biomarkers into clinical practice could improve early detection, patient prognosis, and treatment monitoring in oral carcinoma patients, ultimately enhancing patient outcomes. However, further research should validate these findings in larger cohorts and explore their longitudinal applicability to confirm their clinical utility.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study demonstrated the significant utility of serum β2-microglobulin (β2 M) and lipid-bound sialic acid (LSA) levels as biomarkers for diagnosing and assessing the severity of oral carcinoma. Elevated levels of β2 M and LSA were strongly associated with the presence and progression of the disease, with β2 M showing particularly high diagnostic accuracy. Additionally, the analysis highlighted important demographic and clinical characteristics, such as the greater prevalence of cases in older age groups and the significant association of habits such as alcoholism and smoking with oral carcinoma. The study also emphasized the clinical impact of these interventions, with patients exhibiting lower Karnofsky Performance Status and poor oral hygiene. These findings underscore the importance of early detection and intervention, suggesting that β2 M and LSA levels could play a crucial role in improving patient management and outcomes. However, further research with larger cohorts is needed to validate the effectiveness of these biomarkers and explore their potential for long-term disease monitoring.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST:\u0026nbsp;\u003c/strong\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSOURCE OF FUNDING:\u0026nbsp;\u003c/strong\u003eThe study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT:\u0026nbsp;\u003c/strong\u003eWritten informed consent\u0026nbsp;was\u0026nbsp;obtained from all participants in accordance with international or university standards and\u0026nbsp;was obtained from\u0026nbsp;the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICAL APPROVAL:\u0026nbsp;\u003c/strong\u003eEthical approval was granted in compliance with international or university standards, and written approval was obtained from the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAsthana S, Patil RS, Labani S (2016) Tobaccorelated cancers in India: A review of incidence reported from populationbased cancer registries. Indian J Med Paediatr Oncol 37:152\u0026ndash;157\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorse V, Konwar AN, Buragohain P (2020) Oral cancer diagnosis and perspectives in India. Sens Int 1:100046\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSankaranarayanan R, Ramadas K, Thomas G, Muwonge R, Thara S, Mathew B et al (2005) Effect of screening on oral cancer mortality in Kerala, India: A clusterrandomized controlled trial. Lancet 365:1927\u0026ndash;1933\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNosratzehi T (2017) Salivary chemical factors in relation with oral cancer in smokers and nonsmokers: a literature review. J Dent 18(4):237\u0026ndash;243\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh AP, Kumar N, Raju MS, Singh NN, Nagendrareddy SG (2014) Estimation of serum beta2-microglobulin in potentially malignant disorders and squamous cell carcinoma of the oral cavity: a clinicopathological study. 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J Oral Maxillofacial Pathol 9(1):16\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"upums","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Oral carcinoma, β2-microglobulin (β2 M), lipid-bound sialic acid (LSA), biomarkers, early detection, prognosis","lastPublishedDoi":"10.21203/rs.3.rs-5205822/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5205822/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eOral cancer is a significant global health issue, and nearly one-third of cases are in India. The late-stage diagnosis common in India leads to poor survival outcomes, highlighting the need for early detection and effective biomarkers.\u003c/p\u003e\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eThis study explored the potential of serum β2-microglobulin (β2 M) and lipid-bound sialic acid (LSA) as diagnostic and prognostic biomarkers for oral carcinoma, with a focus on the Indian population, where the disease burden is exceptionally high.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eThis case‒control study involved 200 participants (100 oral cancer patients and 100 healthy controls) aged\u0026thinsp;\u0026gt;\u0026thinsp;20\u0026ndash;60 years. Serum β2 M and LSA levels were measured using ELISA kits. All the statistical analyses, including ROC analysis and correlation studies, were performed using SPSS software to assess the diagnostic accuracy and clinical relevance of these biomarkers.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eSerum β2 M and LSA levels were significantly greater in oral cancer patients than in controls, with β2 M showing near-perfect diagnostic accuracy (AUC 0.999) and LSA demonstrating excellent accuracy (AUC 0.945). Both biomarkers strongly correlated with advanced AJCC stages, underscoring their potential in assessing disease severity and aiding early detection.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eSerum β2 M and LSA levels are promising biomarkers for the diagnosis and assessment of oral carcinoma. Their incorporation into clinical practice could enhance early detection, prognosis, and treatment monitoring, ultimately improving patient outcomes. However, further research with larger cohorts is needed to validate these findings and explore their longitudinal applicability.\u003c/p\u003e","manuscriptTitle":"A Study of Serum Beta 2-microglobulin (β2 M) and Lipid Bound Sialic Acid (Lsa) Levels in Oral Carcinoma Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-10 12:54:35","doi":"10.21203/rs.3.rs-5205822/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fcacb57d-1b40-41a6-ac0f-f7e630721d18","owner":[],"postedDate":"October 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":38678938,"name":"Oncology"}],"tags":[],"updatedAt":"2024-10-17T15:36:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-10 12:54:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5205822","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5205822","identity":"rs-5205822","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}