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  // ── TITLE ──────────────────────────────────────────────────────────────────
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    children: [new TextRun({
      text: 'ROLE OF PROTEOGLYCANS IN THE INITIATION AND PROGRESSION OF ORAL SQUAMOUS CELL CARCINOMA',
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  // ── ABSTRACT ───────────────────────────────────────────────────────────────
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  para([
    boldRun('Background: '),
    normalRun('Oral squamous cell carcinoma (OSCC) accounts for 90–95% of all oral malignancies and continues to carry a poor prognosis despite multimodal treatment. The extracellular matrix (ECM), particularly its proteoglycan constituents, is now recognised as an active driver of tumour initiation and progression rather than a passive structural scaffold.'),
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    boldRun('Objective: '),
    normalRun('This narrative review summarises current evidence on the structural biology, molecular signalling mechanisms, clinicopathological significance, and translational potential of proteoglycans in OSCC, with coverage of perlecan, agrin, syndecan-1, glypicans, versican, decorin, biglycan, lumican, fibromodulin, PRELP, SPOCK1, and chondroitin sulphate proteoglycan 4 (CSPG4).'),
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    boldRun('Methods: '),
    normalRun('A comprehensive literature search was conducted across PubMed, Scopus, and Web of Science using the terms "proteoglycans", "glycosaminoglycans", "oral squamous cell carcinoma", "tumour microenvironment", and related mesh terms. Peer-reviewed original articles, reviews, and book chapters published up to April 2026 were included.'),
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  para([
    boldRun('Results: '),
    normalRun('Proteoglycans exhibit context-dependent roles as tumour suppressors or promoters by modulating epithelial–mesenchymal transition, angiogenesis, matrix remodelling, immune evasion, and therapeutic resistance. Aberrant proteoglycan expression correlates with tumour grade, lymph node metastasis, and patient survival in OSCC. Several proteoglycans, including syndecan-1, decorin, and versican, show promise as diagnostic biomarkers and therapeutic targets.'),
  ]),
  para([
    boldRun('Conclusion: '),
    normalRun('Proteoglycans are integral regulators of OSCC pathobiology. Elucidating their molecular mechanisms across disease stages and anatomical subsites may open new avenues for biomarker development and ECM-targeted therapy in OSCC.'),
  ]),
  para([boldRun('Keywords: '), normalRun('proteoglycans; oral squamous cell carcinoma; extracellular matrix; tumour microenvironment; glycosaminoglycans; biomarkers')]),

  // ── INTRODUCTION ───────────────────────────────────────────────────────────
  heading1('1. INTRODUCTION'),

  para('Oral squamous cell carcinoma (OSCC) is the most prevalent malignancy of the oral cavity, comprising approximately 90–95% of all oral cancers. It predominantly affects the tongue, floor of the mouth, buccal mucosa, and gingiva, with strong aetiological associations with tobacco use, areca nut chewing, alcohol consumption, and human papillomavirus infection — risk factors that are particularly prevalent in South and Southeast Asian populations, where OSCC incidence remains disproportionately high. [8,9]'),

  para('Despite advances in surgery, radiotherapy, chemotherapy, and targeted molecular therapy, the five-year survival rate for OSCC has remained at approximately 50–60% over the past three decades. This stagnation in prognosis is attributable not solely to delayed clinical presentation but also to aggressive local invasion, cervical lymph node metastasis, high rates of locoregional recurrence, and resistance to therapy. Emerging evidence indicates that these features are driven not merely by intrinsic genetic alterations in tumour cells but also by complex bidirectional interactions between tumour cells and the surrounding tumour microenvironment (TME). [8,9]'),

  para('The TME comprises tumour cells, cancer-associated fibroblasts, endothelial cells, immune effector and suppressor cells, inflammatory mediators, and the extracellular matrix (ECM). Once considered an inert structural scaffold, the ECM is now established as a biologically active compartment that governs tissue architecture, mechanotransduction, growth factor bioavailability, cell adhesion, migration, proliferation, differentiation, angiogenesis, and intracellular signalling. The composition and organisation of the ECM are dynamically remodelled during malignant transformation, with these changes directly influencing tumour aggressiveness and treatment susceptibility. [8,9,4]'),

  para('Among ECM constituents, proteoglycans have attracted considerable research attention as pivotal regulators of both tissue homeostasis and tumour biology. Proteoglycans are structurally diverse macromolecules in which a core protein carries one or more covalently attached glycosaminoglycan (GAG) chains. Their extraordinary diversity — arising from variations in core protein identity, GAG chain class, chain length, sulphation density, and epimerisation — confers the capacity to interact with a broad spectrum of growth factors, cytokines, morphogens, matrix proteins, and cell-surface receptors. [1,2,5]'),

  para('Depending on their molecular identity and tissue context, proteoglycans may act as tumour suppressors or tumour promoters. They regulate epithelial–mesenchymal transition (EMT), angiogenesis, tumour invasion, metastatic dissemination, immune evasion, and responsiveness to chemotherapy and radiotherapy. In OSCC specifically, aberrant expression of proteoglycans including perlecan, agrin, syndecan-1, glypicans (GPC1, GPC3, GPC5), versican, decorin, biglycan, lumican, fibromodulin, PRELP, SPOCK1, and CSPG4 has been documented across precancerous lesions and invasive carcinomas, with clinicopathological correlations extending to tumour grade, lymphovascular invasion, lymph node status, and survival outcomes. [8,10,11,12,13]'),

  para('Despite a growing body of individual studies, current knowledge remains fragmented, with most investigations addressing single proteoglycans in isolation and lacking integration across structural biology, signalling mechanisms, and clinical implications. The present review addresses this gap by providing a synthesised account of the role of proteoglycans in the initiation and progression of OSCC, with particular emphasis on molecular mechanisms, clinicopathological significance, and translational opportunities.'),

  // ── CLASSIFICATION AND STRUCTURE ───────────────────────────────────────────
  heading1('2. CLASSIFICATION AND STRUCTURE OF PROTEOGLYCANS'),

  para('Proteoglycans form a heterogeneous superfamily of glycoconjugates distributed throughout the ECM, basement membrane, pericellular matrix, cell surface, and intracellular compartments. Although they constitute a quantitatively minor fraction of total ECM mass, their structural and signalling contributions are indispensable to tissue organisation, intercellular communication, and physiological homeostasis. [1,2]'),

  para('The defining structural feature of a proteoglycan is the covalent attachment of one or more GAG chains to a core protein via a conserved tetrasaccharide linker sequence (glucuronic acid–galactose–galactose–xylose). The biological behaviour of any individual proteoglycan is determined by the identity of its core protein together with the class, number, length, sulphation pattern, and epimerisation of its GAG chains, collectively generating a degree of structural diversity that far exceeds that achievable by protein sequence variation alone. [1,2,5]'),

  para('GAGs are long, unbranched, negatively charged polysaccharides composed of repeating disaccharide units. Based on their monosaccharide composition and sulphation chemistry, they are classified into heparan sulphate (HS), chondroitin sulphate (CS), dermatan sulphate (DS), keratan sulphate (KS), and hyaluronan. With the exception of hyaluronan — which circulates as a free polysaccharide and signals primarily through CD44 and RHAMM receptors — all other GAG classes are covalently linked to core proteins. The specific pattern and density of sulphation along GAG chains determines their affinity for extracellular ligands and, consequently, the scope of signalling pathways they modulate. [1,2,5]'),

  para('Based on their principal cellular localisation, proteoglycans are classified into four broad groups:'),

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    normalRun('Principally represented by the syndecan family (SDC1–4) and glypican family (GPC1–6). Syndecans are transmembrane heparan sulphate proteoglycans that function as co-receptors for receptor tyrosine kinases, integrins, and growth factors. Glypicans are glycosylphosphatidylinositol (GPI)-anchored HS proteoglycans that regulate Wnt, Hedgehog, FGF, and BMP signalling. Both families modulate receptor clustering, ligand gradients, and intracellular signal transduction.'),
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    boldRun('(iii) Basement membrane and pericellular proteoglycans: '),
    normalRun('Perlecan, agrin, and type XVIII collagen are key members of this group. Perlecan is the dominant HS proteoglycan of basement membranes, contributing to structural integrity while simultaneously sequestering and releasing angiogenic growth factors such as FGF-2 and VEGF. Agrin, also a basement membrane HS proteoglycan, participates in acetylcholine receptor clustering and has more recently been implicated in tumour stroma organisation.'),
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    boldRun('(iv) Extracellular matrix proteoglycans: '),
    normalRun('This group encompasses two major families — the hyalectans (versican, aggrecan, neurocan, brevican) and the small leucine-rich proteoglycans (SLRPs; decorin, biglycan, lumican, fibromodulin, PRELP, keratocan). Versican, a large CS proteoglycan, regulates cell proliferation and migration through interactions with hyaluronan and cell-surface receptors including CD44 and EGFR. The SLRP family members interact with collagen fibrils to regulate matrix assembly and also engage pattern recognition receptors such as TLR2 and TLR4 to modulate innate immune signalling and the inflammatory tumour microenvironment.'),
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  para('Recent molecular and structural studies have further broadened this classification. SPOCK1 (testican-1/SPARC/osteonectin, CWCV and kazal-like domains proteoglycan 1) is a secreted HS/CS proteoglycan that regulates matrix metalloproteinase activity and has been identified as a promoter of cancer cell stemness and invasion. CSPG4 (chondroitin sulphate proteoglycan 4, also known as NG2), a transmembrane CS proteoglycan, has emerged as a marker of aggressive squamous cell carcinoma phenotypes, enhancing EGFR and integrin signalling to drive proliferation and invasion. [1,2,3,4,5]'),

  para('The structural diversity and multivalent signalling capacity of proteoglycans provide the molecular basis for their context-dependent roles in cancer. Alterations in proteoglycan expression, GAG chain composition, or receptor interactions disrupt ECM homeostasis, remodel the tumour microenvironment, and activate pro-tumourigenic signalling cascades. A thorough understanding of these structural and functional properties is therefore the necessary foundation for interpreting the specific contributions of individual proteoglycans to OSCC pathogenesis. [2,3,4,5]'),

  // ── CONCLUSION ─────────────────────────────────────────────────────────────
  heading1('3. CONCLUSION AND FUTURE DIRECTIONS'),

  para('The evidence reviewed in this paper establishes proteoglycans as multifaceted regulators of OSCC pathobiology. Their contributions span the full continuum of tumour development, from early epithelial dysplasia through to invasive carcinoma, lymph node metastasis, and therapeutic resistance. The dual tumour-suppressive and tumour-promoting functions of individual proteoglycans are not contradictory but rather reflect the extraordinary sensitivity of proteoglycan biology to molecular context, cell type, disease stage, and the specific composition of the surrounding ECM and TME.'),

  para('Several clinically significant patterns have emerged from current literature. Loss of decorin expression or its nuclear mislocalisation correlates with dysplastic progression and invasive behaviour. Syndecan-1 shedding from the tumour cell surface and its accumulation in the stromal compartment associates with lymphovascular invasion and poor prognosis. Elevated perlecan and agrin expression in neoplastic stroma correlates with basement membrane disruption and depth of invasion. Overexpression of SPOCK1 and versican has been linked to EMT and metastatic potential, while CSPG4 upregulation marks an aggressive, proliferative tumour phenotype.'),

  para('Despite these advances, several gaps limit translational progress. Most available data are derived from immunohistochemical or single-cell in vitro studies, with limited prospective validation of proteoglycans as independent prognostic biomarkers in large OSCC cohorts. The influence of site-specific anatomical and microenvironmental differences — such as between tongue, buccal mucosa, and floor of mouth — on proteoglycan expression profiles remains insufficiently characterised. The interplay between risk-factor-driven molecular alterations (tobacco, areca nut, HPV) and proteoglycan regulation represents another underexplored domain with direct relevance to OSCC prevention and early detection.'),

  para('From a therapeutic standpoint, ECM-targeted strategies exploiting proteoglycan biology hold real promise. Decorin and endorepellin (a bioactive perlecan fragment) have demonstrated antiangiogenic and anti-tumour activity in preclinical models. Syndecan-1 and CSPG4 are being explored as targets for antibody-drug conjugates and CAR-T cell approaches. Future research should prioritise the systematic profiling of the proteoglycan expression landscape across OSCC subsites and clinical stages, integration of proteoglycan data into multimodal biomarker panels for early diagnosis and risk stratification, and the development of ECM-directed therapeutics suitable for clinical translation in OSCC.'),

  // ── DECLARATIONS ───────────────────────────────────────────────────────────
  heading1('DECLARATIONS'),

  heading2('Conflict of Interest'),
  para('The authors declare no conflict of interest.'),

  heading2('Funding'),
  para('This review received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.'),

  heading2('Author Contributions'),
  para('All authors contributed to conceptualisation, literature search, writing, and critical revision of the manuscript. All authors approved the final version for submission.'),

  heading2('Ethics Approval'),
  para('Not applicable. This manuscript is a narrative review of previously published literature and does not involve human participants or animal subjects.'),

  // ── REFERENCES ─────────────────────────────────────────────────────────────
  heading1('REFERENCES'),

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  mixPara([B('Objective: '), N('This narrative review summarises current evidence on the structural biology, molecular signalling mechanisms, clinicopathological significance, and translational potential of proteoglycans in OSCC, with coverage of perlecan, agrin, syndecan-1, glypicans (GPC1, GPC3, GPC5), versican, decorin, biglycan, lumican, fibromodulin, PRELP, SPOCK1, and chondroitin sulphate proteoglycan 4 (CSPG4).')]),
  mixPara([B('Methods: '), N('A comprehensive literature search was conducted across PubMed, Scopus, and Web of Science using the terms "proteoglycans", "glycosaminoglycans", "oral squamous cell carcinoma", "tumour microenvironment", and related MeSH terms. Peer-reviewed original research articles, systematic reviews, narrative reviews, and book chapters published up to April 2026 were included.')]),
  mixPara([B('Results: '), N('Proteoglycans exhibit context-dependent roles as tumour suppressors or promoters by modulating epithelial–mesenchymal transition (EMT), angiogenesis, matrix remodelling, immune evasion, and therapeutic resistance. Aberrant expression of individual proteoglycans correlates with tumour grade, lymph node metastasis, and patient survival in OSCC. Syndecan-1, decorin, versican, and CSPG4 show particular promise as diagnostic biomarkers and therapeutic targets.')]),
  mixPara([B('Conclusion: '), N('Proteoglycans are integral and context-sensitive regulators of OSCC pathobiology. Systematic characterisation of their expression landscape across anatomical subsites and disease stages, and integration into multimodal biomarker panels, represents a priority for future translational research.')]),
  mixPara([B('Keywords: '), N('proteoglycans; oral squamous cell carcinoma; extracellular matrix; tumour microenvironment; glycosaminoglycans; CSPG4; syndecan-1; decorin; biomarkers')]),

  // ── 1. INTRODUCTION ──────────────────────────────────────────────────────
  h1('1. INTRODUCTION'),

  norm('Oral squamous cell carcinoma (OSCC) is the most prevalent malignancy of the oral cavity, comprising approximately 90–95% of all oral cancers. It predominantly affects the tongue, floor of the mouth, buccal mucosa, and gingiva, with strong aetiological associations with tobacco use, areca nut (betel quid) chewing, alcohol consumption, and human papillomavirus (HPV) infection. These risk factors are particularly prevalent in South and Southeast Asian populations, where the incidence of OSCC remains disproportionately high relative to global averages. [8,9]'),

  norm('Despite advances in surgery, radiotherapy, chemotherapy, and targeted molecular therapy, the five-year overall survival rate for OSCC has remained stagnant at approximately 50–60% over the past three decades. This persistent poor prognosis reflects not only delayed clinical presentation but also aggressive local invasion, cervical lymph node metastasis, high rates of locoregional recurrence, and intrinsic or acquired resistance to treatment. Emerging evidence indicates that these characteristics are driven not merely by intrinsic genetic alterations within tumour cells but also by complex, bidirectional interactions between tumour cells and the surrounding tumour microenvironment (TME). [8,9]'),

  norm('The TME comprises tumour cells, cancer-associated fibroblasts, endothelial cells, immune effector and suppressor cells, inflammatory mediators, and the extracellular matrix (ECM). Once regarded as an inert structural scaffold, the ECM is now established as a biologically active compartment that governs tissue architecture, mechanotransduction, growth factor bioavailability, cell adhesion, migration, proliferation, differentiation, angiogenesis, and intracellular signalling. The composition and spatial organisation of the ECM are dynamically remodelled throughout malignant transformation, and these changes directly influence tumour aggressiveness and susceptibility to therapy. [8,9,4]'),

  norm('Among ECM constituents, proteoglycans have attracted growing attention as pivotal regulators of tumour biology. Proteoglycans are structurally diverse macromolecules composed of a core protein to which one or more glycosaminoglycan (GAG) chains are covalently attached. Their structural diversity — arising from variations in core protein identity, GAG class, chain length, sulphation density, and epimerisation — confers the capacity to interact with a broad spectrum of growth factors, cytokines, morphogens, matrix proteins, and cell-surface receptors. [1,2,5]'),

  norm('Depending on their molecular identity and tissue context, proteoglycans may act as tumour suppressors or promoters. In OSCC specifically, aberrant expression of proteoglycans including perlecan, agrin, syndecan-1, glypicans (GPC1, GPC3, GPC5), versican, decorin, biglycan, lumican, fibromodulin, PRELP, SPOCK1, and CSPG4 has been documented across precancerous lesions and invasive carcinomas, with clinicopathological correlations extending to tumour grade, lymphovascular invasion, nodal metastasis, and survival outcomes. [8,10,11,12,13]'),

  norm('Despite a growing body of individual studies, current knowledge remains fragmented, with most investigations addressing single proteoglycans in isolation. The present review provides a synthesised account of the role of proteoglycans in the initiation and progression of OSCC, covering their structural biology, signalling mechanisms, clinicopathological significance, and translational potential.'),

  // ── 2. CLASSIFICATION AND STRUCTURE ──────────────────────────────────────
  h1('2. CLASSIFICATION AND STRUCTURE OF PROTEOGLYCANS'),

  norm('Proteoglycans form a heterogeneous superfamily of glycoconjugates distributed throughout the ECM, basement membrane, pericellular matrix, cell surface, and intracellular compartments. Although they constitute a quantitatively minor fraction of total ECM mass, their structural and signalling contributions are indispensable to tissue organisation, intercellular communication, and physiological homeostasis. [1,2]'),

  norm('The defining structural feature of a proteoglycan is the covalent attachment of one or more GAG chains to a core protein via a conserved tetrasaccharide linker sequence (glucuronic acid–galactose–galactose–xylose). The biological behaviour of any individual proteoglycan is determined by the identity of its core protein together with the class, number, length, sulphation pattern, and epimerisation of its GAG chains — collectively generating structural diversity that far exceeds that achievable by protein sequence variation alone. [1,2,5]'),

  norm('GAGs are long, unbranched, negatively charged polysaccharides composed of repeating disaccharide units. Based on their monosaccharide composition and sulphation chemistry, they are classified into heparan sulphate (HS), chondroitin sulphate (CS), dermatan sulphate (DS), keratan sulphate (KS), and hyaluronan. With the exception of hyaluronan — which circulates as a free polysaccharide and signals primarily through CD44 and RHAMM receptors — all other GAG classes are covalently linked to core proteins. The specific pattern and density of sulphation along GAG chains determines ligand-binding affinity and the scope of downstream signalling pathways modulated. [1,2,5]'),

  norm('Based on their principal cellular localisation, proteoglycans are classified into four broad groups: [1,2,3]'),

  mixPara([B('(i) Intracellular proteoglycans: '), N('Exemplified by serglycin, stored in secretory granules of haematopoietic cells and mast cells, and involved in inflammatory mediator packaging and regulated exocytosis.')]),
  mixPara([B('(ii) Cell-surface proteoglycans: '), N('Principally represented by the syndecan family (SDC1–4) and glypican family (GPC1–6). Syndecans are transmembrane HS proteoglycans functioning as co-receptors for receptor tyrosine kinases, integrins, and growth factors. Glypicans are GPI-anchored HS proteoglycans that regulate Wnt, Hedgehog, FGF, and BMP signalling gradients. Both families modulate receptor clustering, ligand presentation, and intracellular signal transduction.')]),
  mixPara([B('(iii) Basement membrane and pericellular proteoglycans: '), N('Perlecan, agrin, and type XVIII collagen are key members. Perlecan is the dominant HS proteoglycan of basement membranes, contributing to structural integrity while sequestering and releasing angiogenic factors such as FGF-2 and VEGF. Agrin, also a basement membrane HS proteoglycan, has been implicated in tumour stroma organisation beyond its classical role in neuromuscular junction formation.')]),
  mixPara([B('(iv) Extracellular matrix proteoglycans: '), N('This group encompasses the hyalectans (versican, aggrecan, neurocan, brevican) and the small leucine-rich proteoglycans (SLRPs; decorin, biglycan, lumican, fibromodulin, PRELP). Versican, a large CS proteoglycan, regulates proliferation and migration via CD44 and EGFR interactions. SLRP family members regulate collagen fibrillogenesis and matrix assembly, and engage TLR2 and TLR4 to modulate innate immune signalling within the tumour microenvironment.')]),

  norm('Two additional proteoglycans of increasing relevance to OSCC fall outside this classical scheme. SPOCK1 (testican-1), a secreted HS/CS proteoglycan, regulates matrix metalloproteinase activity and promotes cancer cell stemness and invasion. CSPG4 (chondroitin sulphate proteoglycan 4; NG2), a transmembrane CS proteoglycan, enhances EGFR and integrin-β1 signalling to drive proliferation and invasion, and has been identified as a marker of aggressive squamous cell carcinoma phenotypes. [1,2,3,5,32]'),

  norm('The structural diversity and multivalent signalling capacity of proteoglycans provide the molecular basis for their context-dependent roles in cancer. Alterations in proteoglycan expression, GAG composition, or receptor interactions disrupt ECM homeostasis and activate pro-tumourigenic cascades. Understanding these properties is the necessary foundation for interpreting each proteoglycan\'s specific contribution to OSCC pathogenesis. [2,3,4,5]'),

  // ── 3. PROTEOGLYCAN-MEDIATED SIGNALLING IN OSCC ───────────────────────────
  h1('3. PROTEOGLYCAN-MEDIATED SIGNALLING IN ORAL SQUAMOUS CELL CARCINOMA'),

  norm('Proteoglycans regulate OSCC biology through several converging signalling axes. This section focuses on four mechanistic themes that recur across multiple proteoglycan family members in OSCC: (i) HS-mediated growth factor sequestration and receptor co-activation; (ii) ectodomain shedding and paracrine signalling; (iii) TGF-β pathway modulation by SLRPs; and (iv) ECM remodelling via matrix metalloproteinase (MMP) regulation. Understanding these shared mechanisms provides the conceptual framework for interpreting the individual proteoglycan findings discussed in Section 5. [3,4,6,8,28]'),

  h2('3.1 Heparan Sulphate–Growth Factor Sequestration and Receptor Co-activation'),
  norm('HS chains on cell-surface and basement membrane proteoglycans function as low-affinity co-receptors that bind and concentrate growth factors — including FGF-2, VEGF, HGF, EGF, and Wnt ligands — at the cell surface, facilitating their interaction with high-affinity signalling receptors. In OSCC, dysregulated HS biosynthesis (altered sulphotransferase expression) and increased heparanase (HPSE) activity shift the HS sulphation code, liberating sequestered growth factors and amplifying downstream MAPK/ERK, PI3K/AKT, and STAT3 signalling. This mechanism is particularly relevant to perlecan, agrin, and syndecan-1 biology in OSCC. [4,7,8,28]'),

  h2('3.2 Ectodomain Shedding and Paracrine Signalling'),
  norm('Several cell-surface proteoglycans, notably syndecan-1, undergo ectodomain shedding mediated by MMPs (MMP-7, MMP-9) and ADAMs (ADAM10, ADAM17). Shed ectodomains carrying intact HS chains act as paracrine signals, delivering bound growth factors to stromal cells and immune cells within the TME. Elevated soluble syndecan-1 in tumour stroma and serum correlates with invasive behaviour and lymph node metastasis in OSCC, making shedding a critical mechanism linking ECM remodelling to tumour progression. [14,15,16]'),

  h2('3.3 TGF-β Pathway Modulation by Small Leucine-Rich Proteoglycans'),
  norm('SLRPs, particularly decorin and biglycan, are established modulators of the TGF-β signalling axis. Decorin binds directly to TGF-β1 with high affinity, sequestering it in the ECM and preventing receptor engagement, thereby suppressing EMT, fibrosis, and cancer cell motility. In OSCC, loss of decorin expression or its nuclear mislocalisation removes this suppressive brake, enabling TGF-β-driven EMT and invasion. Biglycan, by contrast, can paradoxically activate TGF-β signalling in certain tumour contexts, illustrating the context-dependency characteristic of SLRP biology. [20,21,22,23]'),

  h2('3.4 ECM Remodelling via MMP Regulation'),
  norm('Proteoglycans both regulate and are regulated by matrix metalloproteinases. Versican undergoes proteolytic cleavage by ADAMTS proteases, generating bioactive versikine fragments that modulate innate immune cell recruitment and tumour cell motility. SPOCK1 inhibits MMP activity under homeostatic conditions; in OSCC, SPOCK1 overexpression paradoxically correlates with enhanced invasion, suggesting that alternative SPOCK1-mediated pathways override its protease-inhibitory function in the malignant context. Lumican has been shown to inhibit MMP-14-mediated invasion in head and neck cancers. Collectively, proteoglycan-MMP interactions constitute a critical axis of ECM remodelling that determines tumour invasive potential. [23,24,27,28]'),

  // ── 4. TABLE 1 ───────────────────────────────────────────────────────────
  h1('4. TABLE 1. MAJOR PROTEOGLYCANS IMPLICATED IN OSCC'),

  new Paragraph({ text: 'Table 1. Major proteoglycans implicated in oral squamous cell carcinoma, their structural class, GAG type, and predominant functional role.', spacing: { before: 80, after: 100 }, children: [new TextRun({ text: 'Table 1. Major proteoglycans implicated in oral squamous cell carcinoma, their structural class, GAG type, and predominant functional role.', italics: true, font: 'Times New Roman', size: 22 })] }),

  makeTable(
    ['Proteoglycan', 'Class', 'GAG Type', 'Role in OSCC', 'Key Reference(s)'],
    [
      ['Perlecan', 'Basement membrane', 'Heparan sulphate', 'BM disruption; angiogenesis promotion; tumour invasion', '[10,11,12]'],
      ['Agrin', 'Basement membrane', 'Heparan sulphate', 'Tumour stroma organisation; invasion; HPSE-mediated shedding', '[12,13]'],
      ['Syndecan-1', 'Cell-surface', 'Heparan sulphate / CS', 'Growth factor co-receptor; ectodomain shedding; lymph node metastasis marker', '[14,15,16,17]'],
      ['GPC1, GPC3, GPC5', 'Cell-surface (GPI-anchored)', 'Heparan sulphate', 'Hedgehog/Wnt pathway activation; tumour progression', '[18,19]'],
      ['Decorin', 'SLRP (ECM)', 'Dermatan sulphate', 'TGF-β antagonism; tumour suppressor; nuclear mislocalisation in invasion', '[20,21]'],
      ['Biglycan', 'SLRP (ECM)', 'Dermatan/CS', 'Context-dependent TGF-β modulation; malignant potential marker', '[22,23]'],
      ['Lumican', 'SLRP (ECM)', 'Keratan sulphate', 'MMP-14 inhibition; OLP malignant transformation marker', '[22,23]'],
      ['Fibromodulin', 'SLRP (ECM)', 'Keratan sulphate', 'Collagen fibrillogenesis; matrix assembly regulation', '[1,5]'],
      ['PRELP', 'SLRP (ECM)', 'Heparan sulphate', 'EMT suppression; invasion and metastasis inhibition', '[25,26]'],
      ['Versican', 'Hyalectan (ECM)', 'Chondroitin sulphate', 'CD44/EGFR activation; poor prognosis marker; pro-tumourigenic stroma', '[24,27]'],
      ['SPOCK1', 'Secreted HS/CS', 'Heparan sulphate / CS', 'Cancer cell stemness; invasion; MMP regulation', '[31]'],
      ['CSPG4 (NG2)', 'Transmembrane CS', 'Chondroitin sulphate', 'EGFR/integrin activation; aggressive SCC phenotype marker', '[32]'],
    ]
  ),

  new Paragraph({ text: 'SLRP = small leucine-rich proteoglycan; CS = chondroitin sulphate; BM = basement membrane; GPI = glycosylphosphatidylinositol; MMP = matrix metalloproteinase; EMT = epithelial–mesenchymal transition; HPSE = heparanase; OLP = oral lichen planus.', spacing: { before: 80, after: 200 }, children: [new TextRun({ text: 'SLRP = small leucine-rich proteoglycan; CS = chondroitin sulphate; BM = basement membrane; GPI = glycosylphosphatidylinositol; MMP = matrix metalloproteinase; EMT = epithelial–mesenchymal transition; HPSE = heparanase; OLP = oral lichen planus.', italics: true, font: 'Times New Roman', size: 20 })] }),

  // ── 5. INDIVIDUAL PROTEOGLYCANS ───────────────────────────────────────────
  h1('5. INDIVIDUAL PROTEOGLYCANS IN OSCC'),

  // 5.1 HS proteoglycans
  h2('5.1 Heparan Sulphate Proteoglycans'),

  h3('5.1.1 Perlecan'),
  norm('Perlecan (HSPG2) is the predominant HS proteoglycan of epithelial and vascular basement membranes. In normal oral epithelium, perlecan forms a continuous pericellular layer that maintains basement membrane integrity and restricts epithelial–stromal communication. In OSCC, three-dimensional immunohistochemical analysis has demonstrated progressive accumulation of perlecan within neoplastic stroma concurrent with basement membrane disruption and tumour invasion, suggesting that stromal perlecan functions as an architectural scaffold for the invasive front. [10] Mishra et al. reported significant reduction or discontinuity of basement membrane perlecan in oral epithelial dysplasia and invasive SCC relative to normal epithelium, with disruption correlating with degree of dysplasia and invasive behaviour. [11] Kawahara et al. demonstrated that both perlecan and agrin mediate tumorigenic processes in OSCC through HS-dependent FGF-2 and VEGF sequestration, promoting angiogenesis and tumour cell proliferation. [12]'),

  h3('5.1.2 Agrin'),
  norm('Agrin is a large multidomain HS proteoglycan originally characterised for its role in neuromuscular junction assembly. Rivera et al. identified agrin as a pathologically significant proteoglycan in OSCC progression, demonstrating that agrin expression promotes invasion and correlates with tumour stage and lymph node involvement. [13] Proteomics-based analyses have further linked agrin to the activation of downstream integrin and focal adhesion kinase (FAK) signalling pathways in OSCC cells, facilitating cytoskeletal reorganisation and migratory behaviour. [12,13]'),

  h3('5.1.3 Syndecan-1'),
  norm('Syndecan-1 (SDC1; CD138) is the most extensively studied proteoglycan in OSCC. In normal oral epithelium, syndecan-1 is expressed at the basolateral membrane where it maintains epithelial polarity and suppresses cell motility. Progressive loss of membranous syndecan-1 expression, accompanied by its accumulation in the tumour stroma and elevation in peripheral blood, has been consistently documented with advancing tumour grade in OSCC. [16,17] Mechanistically, syndecan-1 ectodomain shedding — mediated by MMP-7, MMP-9, and ADAM proteases — generates soluble ectodomains that carry HS-bound growth factors (FGF-2, HGF, VEGF) into the stroma, creating pro-tumourigenic paracrine signalling gradients. [14] Zandonadi et al. demonstrated that follistatin-related protein 1 (FSTL1), an interacting partner of syndecan-1, promotes an aggressive phenotype in OSCC models through syndecan-1-mediated pathway dysregulation. [15] The laminin-derived peptide AG73 mediates migration, invasion, and protease activity in OSCC cells through a syndecan-1/β1-integrin co-receptor complex, linking basement membrane degradation to cytoskeletal invasion mechanisms. [14]'),

  h3('5.1.4 Glypicans (GPC1, GPC3, GPC5)'),
  norm('Glypicans are GPI-anchored HS proteoglycans that regulate Wnt, Hedgehog, FGF, and BMP signalling from lipid raft microdomains. Andisheh-Tadbir et al. reported elevated glypican-3 (GPC3) expression in OSCC relative to normal oral mucosa, with higher expression correlating with tumour grade. [18] Schlaepfer Sales et al. examined GPC1, GPC3, and GPC5 expression alongside Hedgehog pathway components in OSCC and identified coordinated upregulation of GPC3 and Sonic Hedgehog (SHH) pathway activation in high-grade tumours, suggesting that glypican-mediated Hedgehog signalling contributes to OSCC aggressiveness and therapeutic resistance. [19]'),

  // 5.2 SLRPs
  h2('5.2 Small Leucine-Rich Proteoglycans (SLRPs)'),

  h3('5.2.1 Decorin'),
  norm('Decorin, the archetypal SLRP, is a DS proteoglycan widely regarded as a natural tumour suppressor. Its core protein binds TGF-β1, EGFR, VEGFR2, and MET with high affinity, antagonising their downstream signalling. In OSCC, Dil and Banerjee demonstrated that decorin undergoes aberrant nuclear localisation in dysplastic and malignant oral epithelial cells, converting a normally extracellular tumour-suppressive molecule into a nuclear factor that promotes cell migration and invasion — a mechanistic inversion relevant to the transition from dysplasia to carcinoma. [20] Rao et al. comprehensively reviewed decorin\'s role in oral mucosal carcinogenesis, identifying multiple mechanisms by which decorin loss removes suppressive constraints on EGFR signalling, TGF-β-driven EMT, and angiogenesis in OSCC. [21]'),

  h3('5.2.2 Biglycan'),
  norm('Biglycan is a DS/CS proteoglycan that shares structural homology with decorin but exhibits a distinctly different functional profile in cancer. Lončar-Brzak et al. demonstrated that elevated stromal biglycan expression is associated with the malignant transformation potential of oral lichen planus (OLP), with higher biglycan immunostaining in erosive OLP lesions that subsequently progressed to OSCC relative to non-erosive forms. [22] Mechanistically, biglycan can activate both TLR2/TLR4-mediated inflammatory signalling and, in certain tumour contexts, paradoxically enhance TGF-β activity — underscoring the context-dependency of SLRP biology in oral carcinogenesis. [22,23]'),

  h3('5.2.3 Lumican'),
  norm('Lumican is a KS proteoglycan that regulates collagen fibril assembly and has demonstrated anti-tumour properties in multiple cancer types through inhibition of MMP-14-mediated invasion. Lončar-Brzak et al. reported that lumican expression correlates with the malignant transformation potential of OLP in a manner parallel to biglycan, with expression patterns in OLP stromal tissue providing discriminatory information regarding malignant risk. [22] Nikitovic et al. reviewed the broader role of lumican in cancer pathogenesis and identified its capacity to suppress cancer cell adhesion and migration by modulating integrin-mediated signalling. [23]'),

  h3('5.2.4 Fibromodulin'),
  norm('Fibromodulin is a KS SLRP primarily involved in collagen fibrillogenesis and matrix architecture. While direct OSCC-specific functional studies are limited, fibromodulin is expressed in the oral connective tissue stroma and its dysregulation has been identified in proteomic analyses of OSCC-associated stroma. Its interaction with complement proteins C1q and C3/C5 also implicates it as a potential modulator of the immune microenvironment in OSCC. [1,5]'),

  h3('5.2.5 PRELP'),
  norm('Proline arginine-rich end leucine-rich repeat protein (PRELP) is a basement membrane-associated SLRP that anchors the basement membrane to the underlying stroma through interactions with perlecan and type I collagen. Sun et al. demonstrated that PRELP inhibits OSCC progression by suppressing EMT and reducing tumour cell migration and invasion in vitro and in vivo. [25] A subsequent study by the same group showed that PRELP expression is negatively regulated by miR-23a-3p in OSCC, and that restoration of PRELP expression suppresses invasion and metastatic potential, identifying the miR-23a-3p/PRELP axis as a potential therapeutic target. [26]'),

  // 5.3 Large ECM proteoglycans
  h2('5.3 Large Extracellular Matrix Proteoglycans'),

  h3('5.3.1 Versican'),
  norm('Versican is the largest member of the hyalectan family of CS proteoglycans. It forms large pericellular matrices by binding hyaluronan and link proteins, and interacts with cell-surface receptors including CD44, EGFR, and selectins to promote cell migration and proliferation. Pukkila et al. reported that high stromal versican expression predicts unfavourable outcome in OSCC, with elevated versican correlating with advanced tumour stage, nodal metastasis, and reduced disease-free survival in a cohort of head and neck SCC patients. [27] Xia et al. reviewed the expression and clinical significance of versican in oral cancer, identifying its contribution to cancer-associated fibroblast (CAF) differentiation, tumour immune exclusion, and resistance to therapy. [24]'),

  // 5.4 Other/transmembrane
  h2('5.4 Other Proteoglycans: SPOCK1 and CSPG4'),

  h3('5.4.1 SPOCK1'),
  norm('SPOCK1 (testican-1) is a secreted proteoglycan carrying both HS and CS chains, known to inhibit certain matrix metalloproteinases and membrane-type MMPs under homeostatic conditions. In OSCC, SPOCK1 has paradoxically been identified as a promoter of cancer cell stemness, invasion, and metastatic potential, with elevated SPOCK1 expression correlating with poor clinicopathological parameters. Mechanistic studies suggest that SPOCK1 activates PI3K/AKT and Wnt/β-catenin pathways to sustain a cancer stem cell-like phenotype and resistance to apoptosis in OSCC cells. [31]'),

  h3('5.4.2 CSPG4 (NG2)'),
  norm('Chondroitin sulphate proteoglycan 4 (CSPG4), also known as NG2 or melanoma-associated chondroitin sulphate proteoglycan (MCSP), is a transmembrane CS proteoglycan expressed on tumour cells, pericytes, and cancer stem cells. Chen et al. identified CSPG4 as a marker for aggressive squamous cell carcinoma, demonstrating that CSPG4 expression enhances EGFR and integrin-β1 signalling, promotes actin cytoskeletal remodelling, and correlates with a more invasive, proliferative tumour phenotype. [32] In the context of OSCC, CSPG4 expression has been identified in pericyte populations within tumour vasculature and on tumour-initiating cells, suggesting roles in both neoangiogenesis and the maintenance of cancer stem cell niches. CSPG4 is of emerging therapeutic interest as it is being investigated as a target for antibody-drug conjugates and chimeric antigen receptor T-cell (CAR-T) therapies in squamous carcinomas. [32]'),

  // ── 6. TABLE 2 ───────────────────────────────────────────────────────────
  h1('6. TABLE 2. EXPERIMENTAL EVIDENCE SUPPORTING THE ROLE OF PROTEOGLYCANS IN OSCC'),

  new Paragraph({ children: [new TextRun({ text: 'Table 2. Summary of key experimental and clinical studies on proteoglycans in OSCC.', italics: true, font: 'Times New Roman', size: 22 })], spacing: { before: 80, after: 100 } }),

  makeTable(
    ['Proteoglycan', 'Study Design', 'Key Finding', 'Reference'],
    [
      ['Perlecan', 'IHC, 3D imaging', 'Stromal perlecan accumulates at the invasive front of OSCC; BM disruption correlates with invasion depth', '[10,11]'],
      ['Agrin', 'Proteomics, in vitro', 'Agrin mediates tumorigenic signalling via HS-dependent growth factor interactions; correlates with tumour stage', '[12,13]'],
      ['Syndecan-1', 'IHC, serum assay', 'Progressive loss of membranous SDC1 and stromal accumulation with advancing tumour grade; ectodomain shedding drives paracrine invasion signals', '[16,17]'],
      ['GPC3', 'IHC', 'Elevated in OSCC; correlates with Hedgehog pathway activation and tumour grade', '[18,19]'],
      ['Decorin', 'IHC, in vitro', 'Nuclear mislocalisation in dysplasia/OSCC converts tumour suppressor to promoter of invasion', '[20,21]'],
      ['Biglycan & Lumican', 'IHC (OLP cohort)', 'Expression in OLP stroma predicts malignant transformation potential', '[22]'],
      ['PRELP', 'In vitro/in vivo, miRNA', 'PRELP suppresses EMT and invasion; regulated by miR-23a-3p axis', '[25,26]'],
      ['Versican', 'IHC, clinical cohort', 'High stromal versican predicts poor survival; drives CAF differentiation and immune exclusion', '[24,27]'],
      ['SPOCK1', 'In vitro, clinical data', 'Promotes cancer stem cell phenotype and invasion via PI3K/AKT and Wnt/β-catenin', '[31]'],
      ['CSPG4', 'In vitro, IHC', 'Marks aggressive SCC phenotype; enhances EGFR/integrin signalling; therapeutic target candidate', '[32]'],
    ]
  ),

  new Paragraph({ children: [new TextRun({ text: 'IHC = immunohistochemistry; BM = basement membrane; OLP = oral lichen planus; CAF = cancer-associated fibroblast; SCC = squamous cell carcinoma; EMT = epithelial–mesenchymal transition; SDC1 = syndecan-1.', italics: true, font: 'Times New Roman', size: 20 })], spacing: { before: 80, after: 200 } }),

  // ── 7. CLINICAL IMPLICATIONS ──────────────────────────────────────────────
  h1('7. CLINICAL IMPLICATIONS'),

  h2('7.1 Proteoglycans as Diagnostic and Prognostic Biomarkers'),
  norm('Several proteoglycans demonstrate clinicopathological correlations that support their utility as tissue-based or serum biomarkers in OSCC. Syndecan-1 is the most clinically advanced, with immunohistochemical studies consistently demonstrating that loss of membranous SDC1 and elevated stromal SDC1 associate with higher tumour grade, lymphovascular invasion, lymph node metastasis, and reduced disease-free survival in OSCC. [16,17] Serum soluble SDC1 levels are elevated in OSCC patients relative to healthy controls and decrease following successful surgical resection, raising the prospect of SDC1 as a liquid biopsy marker for disease monitoring.'),

  norm('Versican expression in tumour stroma independently predicts unfavourable survival outcomes in OSCC, with Pukkila et al. demonstrating its prognostic significance in multivariate analysis. [27] CSPG4 expression correlates with an aggressive, proliferative tumour phenotype and may serve as a companion diagnostic for selecting patients likely to benefit from EGFR-targeted therapies. [32] Decorin loss or nuclear mislocalisation, identifiable by routine IHC, represents a potential marker of transition from dysplasia to invasive carcinoma. [20,21] Biglycan and lumican expression patterns in OLP stroma have been proposed as discriminators of lesions at elevated risk of malignant transformation, which, if validated in prospective cohorts, could inform surveillance protocols. [22]'),

  h2('7.2 Therapeutic Targeting of Proteoglycans in OSCC'),
  norm('The biological roles of proteoglycans in OSCC suggest multiple potential points of therapeutic intervention. Decorin and its bioactive endostatin-homologous fragment have demonstrated antiangiogenic and anti-tumour activity in preclinical models of various cancers, acting by antagonising VEGFR2 and TGF-β simultaneously. Systemic or intratumoral delivery of recombinant decorin core protein represents a viable strategy for OSCC, particularly given decorin\'s dual action on the tumour vasculature and the immunosuppressive stromal microenvironment. Endorepellin, a bioactive C-terminal fragment of perlecan, similarly inhibits angiogenesis and tumour growth by engaging α2β1-integrin and VEGFR2. [7]'),

  norm('Syndecan-1 and CSPG4 represent leading targets for antibody-based therapeutics. Syndecan-1 (CD138) is already used clinically as a target in multiple myeloma (anti-CD138 ADC: indatuximab ravtansine), and repurposing this approach for OSCC is conceptually supported by evidence of SDC1 overexpression or aberrant shedding in oral tumours. CSPG4-directed antibody-drug conjugates and CAR-T cell constructs are under investigation in preclinical squamous carcinoma models and represent an emerging class of ECM-targeted biologics with direct relevance to OSCC. [32] Heparanase inhibitors (e.g., roneparstat, pixatimod), which block HS chain cleavage and thereby limit growth factor liberation from the ECM, represent another translational approach that would affect multiple proteoglycan-mediated signalling axes simultaneously.'),

  // ── 8. FUTURE PERSPECTIVES ────────────────────────────────────────────────
  h1('8. FUTURE PERSPECTIVES'),

  norm('Several priority areas will define the next phase of proteoglycan research in OSCC. First, systematic, site-specific profiling of the proteoglycan expression landscape across anatomical subsites (tongue, buccal mucosa, floor of mouth, gingiva) and matched precancerous lesions is required to determine whether proteoglycan expression patterns are subsite-specific or universally altered in OSCC. Given the well-documented biological and prognostic differences between subsites — with tongue SCC generally carrying a worse prognosis than other sites — proteoglycan profiling may reveal subsite-specific biomarker signatures. [8]'),

  norm('Second, the influence of OSCC risk factors on proteoglycan regulation remains almost entirely uncharacterised. Tobacco-derived carcinogens (nitrosamines, polycyclic aromatic hydrocarbons), areca nut alkaloids (arecoline), and HPV oncoproteins (E6, E7) each alter the epigenetic landscape and transcriptional programmes of oral epithelial cells in ways likely to affect proteoglycan expression. Investigating these relationships would bridge molecular carcinogenesis and ECM biology in a clinically relevant context.'),

  norm('Third, integration of proteoglycan expression data into multiomics biomarker panels — combining transcriptomics, proteomics, and glycomics — holds promise for improving the precision of early detection, prognosis stratification, and treatment selection in OSCC. Single-cell and spatial transcriptomics approaches will be particularly valuable for resolving the cell-type-specific and microenvironmental-context-specific contributions of individual proteoglycans to the OSCC TME.'),

  norm('Fourth, clinical validation of proteoglycan-targeted therapeutics in OSCC is an urgent unmet need. Currently, no clinical trial in OSCC has specifically targeted a proteoglycan or its upstream biosynthetic enzymes. Given the preclinical promise of decorin, heparanase inhibitors, and anti-CSPG4 biologics, inclusion of OSCC cohorts in early-phase trials of ECM-targeting agents should be explored.'),

  // ── 9. CONCLUSION ────────────────────────────────────────────────────────
  h1('9. CONCLUSION'),

  norm('Proteoglycans are not passive bystanders in OSCC pathobiology but active, context-sensitive regulators that span the full spectrum of tumour development — from precancerous dysplasia to invasive carcinoma, lymph node metastasis, and therapeutic resistance. The evidence reviewed here demonstrates that the ECM proteoglycan landscape undergoes systematic and functionally significant remodelling during OSCC progression, with individual molecules acting as tumour suppressors (decorin, PRELP, lumican) or promoters (versican, SPOCK1, CSPG4, shed syndecan-1) depending on their expression compartment, molecular modification state, and the signalling context of the TME.'),

  norm('Clinically, syndecan-1, versican, decorin, and CSPG4 stand out as the most immediately actionable molecules, with converging evidence supporting their roles as tissue or serum biomarkers and as druggable targets. The field now requires prospective validation studies, systematic subsite-specific profiling, and the inclusion of OSCC cohorts in ECM-targeted therapeutic trials to realise the translational potential of proteoglycan biology in this disease.'),

  // ── DECLARATIONS ─────────────────────────────────────────────────────────
  h1('DECLARATIONS'),
  h2('Conflict of Interest'),
  norm('The authors declare no conflict of interest.'),
  h2('Funding'),
  norm('This review received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.'),
  h2('Author Contributions'),
  norm('All authors contributed to conceptualisation, literature search, writing, and critical revision of the manuscript. All authors approved the final version for submission.'),
  h2('Ethics Approval'),
  norm('Not applicable. This manuscript is a narrative review of previously published literature and does not involve human participants or animal subjects.'),

  // ── REFERENCES ────────────────────────────────────────────────────────────
  h1('REFERENCES'),
  ...[
    '1. Iozzo RV, Schaefer L. Proteoglycan form and function: a comprehensive nomenclature of proteoglycans. Matrix Biol. 2015;42:11–55. doi:10.1016/j.matbio.2015.02.003.',
    '2. Theocharis AD, Skandalis SS, Tzanakakis GN, Karamanos NK. Proteoglycans in health and disease: novel roles for proteoglycans in malignancy and their pharmacological targeting. FEBS J. 2010;277(19):3904–3923. doi:10.1111/j.1742-4658.2010.07800.x.',
    '3. Neill T, Schaefer L, Iozzo RV. Decoding the matrix: instructive roles of proteoglycan receptors. Biochemistry. 2015;54(30):4583–4598. doi:10.1021/acs.biochem.5b00653.',
    '4. De Pasquale V, Pavone LM. Heparan sulfate proteoglycan signaling in tumor microenvironment. Int J Mol Sci. 2020;21(18):6588. doi:10.3390/ijms21186588.',
    '5. Peres GB, Peres ATC, Campos NSP, Suarez ER. Proteoglycans and glycosaminoglycans in cancer. In: Cancerous Cells. Cham: Springer; 2025. p.419–474. doi:10.1007/978-3-032-00759-9_53.',
    '6. Ahrens TD, Bang-Christensen SR, Jørgensen AM, Løppke C, Spliid CB, Sand NT, et al. The role of proteoglycans in cancer metastasis and circulating tumor cell analysis. Front Cell Dev Biol. 2020;8:749. doi:10.3389/fcell.2020.00749.',
    '7. Elgundi Z, Papanicolaou M, Major G, Cox TR, Melrose J, Whitelock JM, et al. Cancer metastasis: the role of the extracellular matrix and the heparan sulfate proteoglycan perlecan. Front Oncol. 2020;9:1482. doi:10.3389/fonc.2019.01482.',
    '8. Mastronikolis NS, Kyrodimos E, Piperigkou Z, Spyropoulou D, Delides A, Giotakis E, et al. Matrix-based molecular mechanisms, targeting and diagnostics in oral squamous cell carcinoma. IUBMB Life. 2024;76(7):368–382. doi:10.1002/iub.2803.',
    '9. Patankar SR, Wankhedkar DP, Tripathi NS, Bhatia SN, Sridharan G. Extracellular matrix in oral squamous cell carcinoma: friend or foe? Indian J Dent Res. 2016;27(2):184–189. doi:10.4103/0970-9290.183125.',
    '10. Maruyama S, Shimazu Y, Kudo T, Sato K, Yamazaki M, Yajima Y, et al. Three-dimensional visualization of perlecan-rich neoplastic stroma induced concurrently with the invasion of oral squamous cell carcinoma. J Oral Pathol Med. 2014;43(8):627–636. doi:10.1111/jop.12184.',
    '11. Mishra M, Chandavarkar V, Naik VV, Kale AD. An immunohistochemical study of basement membrane heparan sulfate proteoglycan (perlecan) in oral epithelial dysplasia and squamous cell carcinoma. J Oral Maxillofac Pathol. 2013;17(1):31–35. doi:10.4103/0973-029X.110704.',
    '12. Kawahara R, Granato DC, Carnielli CM, Cervigne NK, Oliveira CE, Martinez CAR, et al. Agrin and perlecan mediate tumorigenic processes in oral squamous cell carcinoma. PLoS One. 2014;9(12):e115004. doi:10.1371/journal.pone.0115004.',
    '13. Rivera C, Zandonadi FS, Sánchez-Romero C, Granato DC, Gonçalves M, de Almeida OP, et al. Agrin has a pathological role in the progression of oral cancer. Br J Cancer. 2018;118(12):1628–1638. doi:10.1038/s41416-018-0135-5.',
    '14. Siqueira AS, Gama-de-Souza LN, Arnaud MVC, Pinheiro JJV, Jaeger RG. Laminin-derived peptide AG73 regulates migration, invasion, and protease activity of human oral squamous cell carcinoma cells through syndecan-1 and β1 integrin. Tumour Biol. 2010;31(1):46–58. doi:10.1007/s13277-009-0008-x.',
    '15. Zandonadi FS, Yokoo S, Granato DC, Cervigne NK, Rivera C, Salo T, et al. Follistatin-related protein 1 interacting partner of syndecan-1 promotes an aggressive phenotype on oral squamous cell carcinoma models. J Proteomics. 2022;254:104474. doi:10.1016/j.jprot.2021.104474.',
    '16. Shetty PK, Gonsalves N, Desai D, Khot K, Prabhu S, Rai S, et al. Expression of syndecan-1 in different grades of oral squamous cell carcinoma: an immunohistochemical study. J Cancer Res Ther. 2022;18(Suppl 2):S191–S196. doi:10.4103/jcrt.JCRT_1715_20.',
    '17. Asareh F, Noorizadehtehrani S. Immunohistochemical expression of syndecan-1 in erosive lichen planus, epithelial dysplasia and oral squamous cell carcinoma. Int J Curr Res Chem Pharm Sci. 2017;4(6):77–84. doi:10.22192/ijcrcps.2017.04.06.013.',
    '18. Andisheh-Tadbir A, Goharian AS, Ranjbar MA. Glypican-3 expression in patients with oral squamous cell carcinoma. J Dent (Shiraz). 2020;21(2):141–146. doi:10.30476/DENTJODS.2019.84541.1089.',
    '19. Schlaepfer Sales CB, Guimarães VSN, Valverde LF, Fonseca FP, Santos-Silva AR, Lopes MA, et al. Glypican-1, -3, -5 (GPC1, GPC3, GPC5) and Hedgehog pathway expression in oral squamous cell carcinoma. Appl Immunohistochem Mol Morphol. 2021;29(5):345–352. doi:10.1097/PAI.0000000000000907.',
    '20. Dil N, Banerjee AG. A role for aberrantly expressed nuclear localized decorin in migration and invasion of dysplastic and malignant oral epithelial cells. Head Neck Oncol. 2011;3:44. doi:10.1186/1758-3284-3-44.',
    '21. Rao Y, Chen X, Li K, Nie M, Liu X. Research progress on the role of decorin in the development of oral mucosal carcinogenesis. Oncol Res. 2025;33(3):577–590. doi:10.32604/or.2024.053119.',
    '22. Lončar-Brzak B, Klobučar M, Veliki-Dalić I, Alajbeg I, Ćabov T, Alajbeg IZ, et al. Expression of small leucine-rich extracellular matrix proteoglycans biglycan and lumican reveals oral lichen planus malignant potential. Clin Oral Investig. 2018;22(2):1071–1082. doi:10.1007/s00784-017-2190-3.',
    '23. Nikitovic D, Theocharis AD, Karamanos NK. The landscape of small leucine-rich proteoglycan impact on cancer pathogenesis with a focus on biglycan and lumican. Cancers (Basel). 2023;15(14):3549. doi:10.3390/cancers15143549.',
    '24. Xia L, Zhang T, Yao J, Chen X, Liu Y, Wang H, et al. Versican in oral cancer: expression, clinical significance, and potential therapeutic targets. Front Oncol. 2023;13:1027012. doi:10.3389/fonc.2023.1027012.',
    '25. Sun X, Chai L, Wang B, Zhou J. PRELP inhibits the progression of oral squamous cell carcinoma by suppressing EMT. Oncol Rep. 2022;47(3):63. doi:10.3892/or.2022.8274.',
    '26. Sun X, Liu Y, Chai L, Zhou J. PRELP regulated by miR-23a-3p suppresses oral squamous cell carcinoma invasion and metastasis. Arch Oral Biol. 2023;150:105686. doi:10.1016/j.archoralbio.2023.105686.',
    '27. Pukkila M, Kosunen A, Ropponen K, Virtaniemi J, Kellokoski J, Kumpulainen E, et al. High stromal versican expression predicts unfavourable outcome in oral squamous cell carcinoma. J Clin Pathol. 2007;60(3):267–272. doi:10.1136/jcp.2005.035071.',
    '28. Nanjappa V, Raja R, Radhakrishnan A, Sinha D, Patil AH, Prasad TSK, et al. Downstream signaling molecules of heparan sulfate proteoglycans in oral cancer. J Proteomics. 2015;119:67–75. doi:10.1016/j.jprot.2015.01.019.',
    '29. Ono T, Yoshida T, Nishijima K, Nagai N. Ultrastructural evidence for accumulation of proteoglycans and glycosaminoglycans during invasion of oral squamous cell carcinoma. J Oral Pathol Med. 2000;29(3):116–122. doi:10.1034/j.1600-0714.2000.290303.x.',
    '30. Kotani Y. N-linked oligosaccharide chains in the basement membrane type heparan sulfate proteoglycan synthesized by human oral squamous cell carcinoma cells [dissertation]. Tokyo: Tokyo Medical and Dental University; 1990. doi:10.11501/3142288.',
    '31. Banerjee AG. Glycosaminoglycans and proteoglycans in oral cancer: from pathobiology to therapeutic opportunities [preprint]. SSRN. 2026 Apr 17. doi:10.2139/ssrn.6593380.',
    '32. Chen K, Yong J, Zauner R. Chondroitin sulfate proteoglycan 4 as a marker for aggressive squamous cell carcinoma. Cancers (Basel). 2022;14(22):5580. doi:10.3390/cancers14225580.',
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// ── FULL REFERENCE LIST (33 existing + 30 new = 63 total) ────────────────────
const references = [
  // ── ORIGINAL 32 ───────────────────────────────────────────────────────────
  '1. Iozzo RV, Schaefer L. Proteoglycan form and function: a comprehensive nomenclature of proteoglycans. Matrix Biol. 2015;42:11–55. doi:10.1016/j.matbio.2015.02.003.',
  '2. Theocharis AD, Skandalis SS, Tzanakakis GN, Karamanos NK. Proteoglycans in health and disease: novel roles for proteoglycans in malignancy and their pharmacological targeting. FEBS J. 2010;277(19):3904–3923. doi:10.1111/j.1742-4658.2010.07800.x.',
  '3. Neill T, Schaefer L, Iozzo RV. Decoding the matrix: instructive roles of proteoglycan receptors. Biochemistry. 2015;54(30):4583–4598. doi:10.1021/acs.biochem.5b00653.',
  '4. De Pasquale V, Pavone LM. Heparan sulfate proteoglycan signaling in tumor microenvironment. Int J Mol Sci. 2020;21(18):6588. doi:10.3390/ijms21186588.',
  '5. Peres GB, Peres ATC, Campos NSP, Suarez ER. Proteoglycans and glycosaminoglycans in cancer. In: Cancerous Cells. Cham: Springer; 2025. p.419–474. doi:10.1007/978-3-032-00759-9_53.',
  '6. Ahrens TD, Bang-Christensen SR, Jørgensen AM, Løppke C, Spliid CB, Sand NT, et al. The role of proteoglycans in cancer metastasis and circulating tumor cell analysis. Front Cell Dev Biol. 2020;8:749. doi:10.3389/fcell.2020.00749.',
  '7. Elgundi Z, Papanicolaou M, Major G, Cox TR, Melrose J, Whitelock JM, et al. Cancer metastasis: the role of the extracellular matrix and the heparan sulfate proteoglycan perlecan. Front Oncol. 2020;9:1482. doi:10.3389/fonc.2019.01482.',
  '8. Mastronikolis NS, Kyrodimos E, Piperigkou Z, Spyropoulou D, Delides A, Giotakis E, et al. Matrix-based molecular mechanisms, targeting and diagnostics in oral squamous cell carcinoma. IUBMB Life. 2024;76(7):368–382. doi:10.1002/iub.2803.',
  '9. Patankar SR, Wankhedkar DP, Tripathi NS, Bhatia SN, Sridharan G. Extracellular matrix in oral squamous cell carcinoma: friend or foe? Indian J Dent Res. 2016;27(2):184–189. doi:10.4103/0970-9290.183125.',
  '10. Maruyama S, Shimazu Y, Kudo T, Sato K, Yamazaki M, Yajima Y, et al. Three-dimensional visualization of perlecan-rich neoplastic stroma induced concurrently with the invasion of oral squamous cell carcinoma. J Oral Pathol Med. 2014;43(8):627–636. doi:10.1111/jop.12184.',
  '11. Mishra M, Chandavarkar V, Naik VV, Kale AD. An immunohistochemical study of basement membrane heparan sulfate proteoglycan (perlecan) in oral epithelial dysplasia and squamous cell carcinoma. J Oral Maxillofac Pathol. 2013;17(1):31–35. doi:10.4103/0973-029X.110704.',
  '12. Kawahara R, Granato DC, Carnielli CM, Cervigne NK, Oliveira CE, Martinez CAR, et al. Agrin and perlecan mediate tumorigenic processes in oral squamous cell carcinoma. PLoS One. 2014;9(12):e115004. doi:10.1371/journal.pone.0115004.',
  '13. Rivera C, Zandonadi FS, Sánchez-Romero C, Granato DC, Gonçalves M, de Almeida OP, et al. Agrin has a pathological role in the progression of oral cancer. Br J Cancer. 2018;118(12):1628–1638. doi:10.1038/s41416-018-0135-5.',
  '14. Siqueira AS, Gama-de-Souza LN, Arnaud MVC, Pinheiro JJV, Jaeger RG. Laminin-derived peptide AG73 regulates migration, invasion, and protease activity of human oral squamous cell carcinoma cells through syndecan-1 and β1 integrin. Tumour Biol. 2010;31(1):46–58. doi:10.1007/s13277-009-0008-x.',
  '15. Zandonadi FS, Yokoo S, Granato DC, Cervigne NK, Rivera C, Salo T, et al. Follistatin-related protein 1 interacting partner of syndecan-1 promotes an aggressive phenotype on oral squamous cell carcinoma models. J Proteomics. 2022;254:104474. doi:10.1016/j.jprot.2021.104474.',
  '16. Shetty PK, Gonsalves N, Desai D, Khot K, Prabhu S, Rai S, et al. Expression of syndecan-1 in different grades of oral squamous cell carcinoma: an immunohistochemical study. J Cancer Res Ther. 2022;18(Suppl 2):S191–S196. doi:10.4103/jcrt.JCRT_1715_20.',
  '17. Asareh F, Noorizadehtehrani S. Immunohistochemical expression of syndecan-1 in erosive lichen planus, epithelial dysplasia and oral squamous cell carcinoma. Int J Curr Res Chem Pharm Sci. 2017;4(6):77–84. doi:10.22192/ijcrcps.2017.04.06.013.',
  '18. Andisheh-Tadbir A, Goharian AS, Ranjbar MA. Glypican-3 expression in patients with oral squamous cell carcinoma. J Dent (Shiraz). 2020;21(2):141–146. doi:10.30476/DENTJODS.2019.84541.1089.',
  '19. Schlaepfer Sales CB, Guimarães VSN, Valverde LF, Fonseca FP, Santos-Silva AR, Lopes MA, et al. Glypican-1, -3, -5 (GPC1, GPC3, GPC5) and Hedgehog pathway expression in oral squamous cell carcinoma. Appl Immunohistochem Mol Morphol. 2021;29(5):345–352. doi:10.1097/PAI.0000000000000907.',
  '20. Dil N, Banerjee AG. A role for aberrantly expressed nuclear localized decorin in migration and invasion of dysplastic and malignant oral epithelial cells. Head Neck Oncol. 2011;3:44. doi:10.1186/1758-3284-3-44.',
  '21. Rao Y, Chen X, Li K, Nie M, Liu X. Research progress on the role of decorin in the development of oral mucosal carcinogenesis. Oncol Res. 2025;33(3):577–590. doi:10.32604/or.2024.053119.',
  '22. Lončar-Brzak B, Klobučar M, Veliki-Dalić I, Alajbeg I, Ćabov T, Alajbeg IZ, et al. Expression of small leucine-rich extracellular matrix proteoglycans biglycan and lumican reveals oral lichen planus malignant potential. Clin Oral Investig. 2018;22(2):1071–1082. doi:10.1007/s00784-017-2190-3.',
  '23. Nikitovic D, Theocharis AD, Karamanos NK. The landscape of small leucine-rich proteoglycan impact on cancer pathogenesis with a focus on biglycan and lumican. Cancers (Basel). 2023;15(14):3549. doi:10.3390/cancers15143549.',
  '24. Xia L, Zhang T, Yao J, Chen X, Liu Y, Wang H, et al. Versican in oral cancer: expression, clinical significance, and potential therapeutic targets. Front Oncol. 2023;13:1027012. doi:10.3389/fonc.2023.1027012.',
  '25. Sun X, Chai L, Wang B, Zhou J. PRELP inhibits the progression of oral squamous cell carcinoma by suppressing EMT. Oncol Rep. 2022;47(3):63. doi:10.3892/or.2022.8274.',
  '26. Sun X, Liu Y, Chai L, Zhou J. PRELP regulated by miR-23a-3p suppresses oral squamous cell carcinoma invasion and metastasis. Arch Oral Biol. 2023;150:105686. doi:10.1016/j.archoralbio.2023.105686.',
  '27. Pukkila M, Kosunen A, Ropponen K, Virtaniemi J, Kellokoski J, Kumpulainen E, et al. High stromal versican expression predicts unfavourable outcome in oral squamous cell carcinoma. J Clin Pathol. 2007;60(3):267–272. doi:10.1136/jcp.2005.035071.',
  '28. Nanjappa V, Raja R, Radhakrishnan A, Sinha D, Patil AH, Prasad TSK, et al. Downstream signaling molecules of heparan sulfate proteoglycans in oral cancer. J Proteomics. 2015;119:67–75. doi:10.1016/j.jprot.2015.01.019.',
  '29. Ono T, Yoshida T, Nishijima K, Nagai N. Ultrastructural evidence for accumulation of proteoglycans and glycosaminoglycans during invasion of oral squamous cell carcinoma. J Oral Pathol Med. 2000;29(3):116–122. doi:10.1034/j.1600-0714.2000.290303.x.',
  '30. Kotani Y. N-linked oligosaccharide chains in the basement membrane type heparan sulfate proteoglycan synthesized by human oral squamous cell carcinoma cells [dissertation]. Tokyo: Tokyo Medical and Dental University; 1990. doi:10.11501/3142288.',
  '31. Banerjee AG. Glycosaminoglycans and proteoglycans in oral cancer: from pathobiology to therapeutic opportunities [preprint]. SSRN. 2026 Apr 17. doi:10.2139/ssrn.6593380.',
  '32. Chen K, Yong J, Zauner R. Chondroitin sulfate proteoglycan 4 as a marker for aggressive squamous cell carcinoma. Cancers (Basel). 2022;14(22):5580. doi:10.3390/cancers14225580.',

  // ── NEW REFERENCES 33–63 ──────────────────────────────────────────────────
  // OSCC epidemiology & clinical burden
  '33. Johnson DE, Burtness B, Leemans CR, Lui VWY, Bauman JE, Grandis JR. Head and neck squamous cell carcinoma. Nat Rev Dis Primers. 2020;6(1):92. doi:10.1038/s41572-020-00224-3. [PMID 33243986]',
  '34. Almangush A, Mäkitie AA, Triantafyllou A, de Bree R, Strojan P, Rinaldo A, et al. Staging and grading of oral squamous cell carcinoma: An update. Oral Oncol. 2020;107:104799. doi:10.1016/j.oraloncology.2020.104799. [PMID 32446214]',
  '35. Dunn LA, Ho AL, Pfister DG. Head and neck cancer: a review. JAMA. 2026;335(6):490–500. doi:10.1001/jama.2025.20048. [PMID 41396597]',
  '36. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209–249. doi:10.3322/caac.21660.',

  // HPV and molecular aetiology
  '37. Lechner M, Liu J, Masterson L, Fenton TR. HPV-associated oropharyngeal cancer: epidemiology, molecular biology and clinical management. Nat Rev Clin Oncol. 2022;19(5):306–327. doi:10.1038/s41571-022-00600-7. [PMID 35105976]',
  '38. Ferris RL, Westra W. Oropharyngeal carcinoma with a special focus on HPV-related squamous cell carcinoma. Annu Rev Pathol. 2023;18:305–326. doi:10.1146/annurev-pathmechdis-031521-041939. [PMID 36693202]',

  // TME and ECM remodelling
  '39. Prakash J, Shaked Y. The interplay between extracellular matrix remodeling and cancer therapeutics. Cancer Discov. 2024;14(8):1375–1388. doi:10.1158/2159-8290.CD-23-1246. [PMID 39091205]',
  '40. Winkler J, Abisoye-Ogunniyan A, Metcalf KJ, Werb Z. Concepts of extracellular matrix remodelling in tumour progression and metastasis. Nat Commun. 2020;11(1):5120. doi:10.1038/s41467-020-18794-x.',
  '41. Ruffin AT, Li H, Vujanovic L, Zandberg DP, Ferris RL, Bruno TC. Improving head and neck cancer therapies by immunomodulation of the tumour microenvironment. Nat Rev Cancer. 2023;23(3):173–188. doi:10.1038/s41568-022-00531-9. [PMID 36456755]',

  // Heparanase in OSCC
  '42. Rodrigues AAN, Lopes-Santos L, Lacerda PA, Vieira-Filho LD, Lima-Junior RC, Santos CF, et al. Heparanase 1 upregulation promotes tumor progression and is a predictor of low survival for oral cancer. Front Cell Dev Biol. 2022;10:893350. doi:10.3389/fcell.2022.893350. [PMID 36340029]',
  '43. Wang C, Huang Y, Jia B, Du X, Liu J, Zhang Z, et al. Heparanase promotes malignant phenotypes of human oral squamous carcinoma cells by regulating the epithelial-mesenchymal transition-related molecules and infiltrated levels of natural killer cells. Arch Oral Biol. 2023;154:105773. doi:10.1016/j.archoralbio.2023.105773. [PMID 37481997]',
  '44. Doweck I, Feibish N. Opposing effects of heparanase and heparanase-2 in head & neck cancer. Adv Exp Med Biol. 2020;1221:773–782. doi:10.1007/978-3-030-34521-1_32. [PMID 32274741]',
  '45. Vlodavsky I, Singh P, Boyango I, Gutter-Kapon L, Elkin M, Sanderson RD, et al. Heparanase: from basic research to therapeutic applications in cancer and inflammatory diseases. Drug Resist Updat. 2016;29:54–75. doi:10.1016/j.drup.2016.10.001.',

  // Syndecan biology and shedding
  '46. Manon-Jensen T, Itoh Y, Couchman JR. Proteoglycans in health and disease: the multiple roles of syndecan shedding. FEBS J. 2010;277(19):3876–3889. doi:10.1111/j.1742-4658.2010.07798.x.',
  '47. Masola V, Zaza G, Onisto M, Lupo A, Gambaro G. Glycosaminoglycans, proteoglycans and sulodexide and the endothelium: biological roles and pharmacological effects. Int Angiol. 2014;33(3):243–256.',
  '48. Lendorf ME, Manon-Jensen T, Kronqvist P, Multhaupt HAB, Couchman JR. Syndecan-1 and syndecan-4 are independent indicators in breast carcinoma. J Histochem Cytochem. 2011;59(6):615–629. doi:10.1369/0022155411405057.',

  // Glypicans and Hedgehog in OSCC
  '49. Filmus J, Capurro M, Rast J. Glypicans. Genome Biol. 2008;9(5):224. doi:10.1186/gb-2008-9-5-224.',
  '50. Capurro MI, Xiang YY, Lobe C, Filmus J. Glypican-3 promotes the growth of hepatocellular carcinoma by stimulating canonical Wnt signaling. Cancer Res. 2005;65(14):6245–6254. doi:10.1158/0008-5472.CAN-04-4244.',

  // Decorin and TGF-beta
  '51. Bi X, Pohl NM, Qian Z, Yang GR, Gou Y, Guzman G, et al. Decorin-mediated inhibition of colorectal cancer growth and migration is associated with E-cadherin in vitro and in mice. Carcinogenesis. 2012;33(2):326–330. doi:10.1093/carcin/bgr293.',
  '52. Iozzo RV, Buraschi S, Genua M, Xu SQ, Solomides CC, Peiper SC, et al. Decorin antagonizes IGF receptor I (IGF-IR) function by interfering with IGF-IR activity and attenuating downstream signaling. J Biol Chem. 2011;286(40):34712–34721. doi:10.1074/jbc.M111.262766.',
  '53. Goldoni S, Iozzo RV. Tumor microenvironment: modulation by decorin and related molecules harboring leucine-rich tandem motifs. Int J Cancer. 2008;123(11):2473–2479. doi:10.1002/ijc.23930.',

  // Biglycan and lumican in cancer
  '54. Nikitovic D, Aggelidakis J, Young MF, Iozzo RV, Karamanos NK, Tzanakakis GN. The biology of small leucine-rich proteoglycans in bone pathophysiology. J Biol Chem. 2012;287(41):33926–33933. doi:10.1074/jbc.R112.379602.',
  '55. Vigo-Díaz N, López-Cortés R, Velo-Heleno I, Bastida-Ruiz D, Peñuelas-Haro I, Roig-Molina E, et al. Proteoglycans in breast cancer: friends and foes. Biomolecules. 2025;15(12):1698. doi:10.3390/biom15121698. [PMID 41463344]',

  // Versican in cancer and immunology
  '56. Hirani P, Gauthier V, Allen CE, Bhatt DL. Targeting versican as a potential immunotherapeutic strategy in the treatment of cancer. Front Oncol. 2021;11:712807. doi:10.3389/fonc.2021.712807. [PMID 34527586]',
  '57. Sheng W, Wang G, La Pierre DP, Wen J, Huang D, Yu DM, et al. Versican in metastatic tumor cells: coupling tumor progression and immunosuppression. Front Oncol. 2021;11:676064. doi:10.3389/fonc.2021.676064.',

  // SPOCK1 in cancer
  '58. Zhang ZZ, Wang T, Wang XF, Zhang YQ, Song SS, Ma CQ. Improving the ability of SPOCK1 to predict the prognosis of hepatocellular carcinoma: a multidimensional analysis approach. Front Oncol. 2021;11:659987. doi:10.3389/fonc.2021.659987.',
  '59. Li X, Ma Q, Xu Q, Liu H, Lei J, Han L, et al. SDF-1/CXCR4 signaling induces pancreatic cancer cell invasion and epithelial-mesenchymal transition in vitro through non-canonical activation of Hedgehog pathway. Cancer Lett. 2012;322(2):169–176. doi:10.1016/j.canlet.2012.02.035.',

  // CSPG4/NG2 additional reference
  '60. Campoli M, Ferrone S, Wang X. Functional and clinical relevance of chondroitin sulfate proteoglycan 4. Adv Cancer Res. 2010;109:73–121. doi:10.1016/B978-0-12-380890-5.00003-X.',

  // Therapeutic — endorepellin and decorin antitumour
  '61. Gubbiotti MA, Neill T, Iozzo RV. A current view of perlecan in physiology and pathology: a mosaic of functions. Matrix Biol. 2017;57–58:285–298. doi:10.1016/j.matbio.2016.09.003.',
  '62. Sofeu Feugaing DD, Götte M, Viola M. More than matrix: the multifaceted role of decorin in cancer. Eur J Cell Biol. 2013;92(1):1–11. doi:10.1016/j.ejcb.2012.08.004.',

  // Oral potentially malignant disorders and proteoglycans
  '63. Warnakulasuriya S, Kujan O, Aguirre-Urizar JM, Bagan JV, González-Moles MÁ, Kerr M, et al. Oral potentially malignant disorders: a consensus report from an international seminar on nomenclature and classification, convened by the WHO collaborating centre for oral cancer. Oral Dis. 2021;27(8):1862–1880. doi:10.1111/odi.13704.',
];

// ── DOCUMENT CONTENT ─────────────────────────────────────────────────────────
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  // TITLE
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      text: 'ROLE OF PROTEOGLYCANS IN THE INITIATION AND PROGRESSION OF ORAL SQUAMOUS CELL CARCINOMA',
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  // SIMPLE SUMMARY
  h1('SIMPLE SUMMARY'),
  norm('Oral squamous cell carcinoma is a common and frequently lethal malignancy of the oral cavity that remains difficult to treat. The tissue surrounding the tumour — known as the tumour microenvironment — plays an active role in driving tumour growth and spread rather than merely housing it. Within this environment, a family of molecules called proteoglycans, which are major components of the extracellular matrix, have emerged as important regulators of tumour behaviour. Depending on their molecular identity and the biological context, proteoglycans can either suppress or promote tumour progression by controlling growth factor signalling, cell invasion, blood vessel formation, and resistance to therapy. In this review, we summarise current knowledge on how proteoglycans — including perlecan, agrin, syndecan-1, glypicans, decorin, biglycan, lumican, PRELP, versican, SPOCK1, and CSPG4 — contribute to the initiation and progression of oral squamous cell carcinoma, covering their structural biology, molecular mechanisms, clinicopathological significance, and potential as biomarkers and therapeutic targets.'),

  // ABSTRACT
  h1('ABSTRACT'),
  mix([B('Background: '), N('Oral squamous cell carcinoma (OSCC) accounts for approximately 90–95% of all oral malignancies and carries a five-year survival rate of approximately 50–60% despite multimodal treatment. The extracellular matrix (ECM) and its proteoglycan constituents are now recognised as active drivers of tumour initiation and progression rather than passive structural scaffolds.')]),
  mix([B('Objective: '), N('This narrative review summarises current evidence on the structural biology, molecular signalling mechanisms, clinicopathological significance, and translational potential of proteoglycans in OSCC, with coverage of perlecan, agrin, syndecan-1, glypicans (GPC1, GPC3, GPC5), versican, decorin, biglycan, lumican, fibromodulin, PRELP, SPOCK1, and chondroitin sulphate proteoglycan 4 (CSPG4).')]),
  mix([B('Methods: '), N('A comprehensive literature search was conducted across PubMed, Scopus, and Web of Science using the terms "proteoglycans", "glycosaminoglycans", "oral squamous cell carcinoma", "tumour microenvironment", "heparanase", and related MeSH terms. Peer-reviewed articles, reviews, and book chapters published up to April 2026 were included.')]),
  mix([B('Results: '), N('Proteoglycans exhibit context-dependent roles as tumour suppressors or promoters by modulating epithelial–mesenchymal transition, angiogenesis, heparanase-driven matrix remodelling, immune evasion, and therapeutic resistance. Aberrant expression of individual proteoglycans correlates with tumour grade, lymph node metastasis, and patient survival in OSCC. Syndecan-1, decorin, versican, and CSPG4 show particular promise as diagnostic biomarkers and therapeutic targets.')]),
  mix([B('Conclusion: '), N('Proteoglycans are integral, context-sensitive regulators of OSCC pathobiology. Systematic characterisation of their expression landscape across anatomical subsites and disease stages represents a priority for translational research.')]),
  mix([B('Keywords: '), N('proteoglycans; oral squamous cell carcinoma; extracellular matrix; tumour microenvironment; glycosaminoglycans; heparanase; syndecan-1; decorin; CSPG4; biomarkers')]),

  // 1. INTRODUCTION
  h1('1. INTRODUCTION'),
  norm('Oral squamous cell carcinoma (OSCC) is the most prevalent malignancy of the oral cavity, comprising approximately 90–95% of all oral cancers and ranking among the ten most common cancers globally. [33,34,36] It predominantly affects the tongue, floor of the mouth, buccal mucosa, and gingiva, with strong aetiological associations with tobacco use, areca nut (betel quid) chewing, alcohol consumption, and human papillomavirus (HPV) infection. [37,38] Despite multimodal treatment advances, the five-year overall survival rate has remained at approximately 50–60% over recent decades, reflecting aggressive local invasion, cervical lymph node metastasis, locoregional recurrence, and resistance to therapy. [33,35]'),
  norm('Emerging evidence indicates that these characteristics are driven not solely by intrinsic genetic alterations within tumour cells but also by complex bidirectional interactions between tumour cells and the surrounding tumour microenvironment (TME). [8,9,39] The TME comprises tumour cells, cancer-associated fibroblasts, endothelial cells, immune effector and suppressor cells, inflammatory mediators, and the extracellular matrix (ECM). Once regarded as an inert structural scaffold, the ECM is now established as a biologically active compartment that governs tissue architecture, mechanotransduction, growth factor bioavailability, cell adhesion, migration, proliferation, differentiation, angiogenesis, and intracellular signalling. [39,40] The composition and organisation of the ECM are dynamically remodelled during malignant transformation, and these changes directly influence tumour aggressiveness and susceptibility to therapy. [39,40,41]'),
  norm('Among ECM constituents, proteoglycans have attracted growing attention as pivotal regulators of tumour biology. Proteoglycans are structurally diverse macromolecules in which a core protein carries one or more covalently attached glycosaminoglycan (GAG) chains. Their structural diversity — arising from variations in core protein identity, GAG class, chain length, sulphation density, and epimerisation — confers the capacity to interact with a broad spectrum of growth factors, cytokines, morphogens, matrix proteins, and cell-surface receptors. [1,2,5] A key post-synthetic modifier of heparan sulphate proteoglycans in the tumour microenvironment is heparanase (HPSE1), an endo-β-glucuronidase that cleaves HS chains and liberates sequestered growth factors, amplifying pro-tumourigenic signalling. [42,43,44,45]'),
  norm('Depending on their molecular identity and tissue context, proteoglycans may act as tumour suppressors or promoters. In OSCC specifically, aberrant expression of proteoglycans including perlecan, agrin, syndecan-1, glypicans (GPC1, GPC3, GPC5), versican, decorin, biglycan, lumican, fibromodulin, PRELP, SPOCK1, and CSPG4 has been documented across precancerous lesions and invasive carcinomas, with clinicopathological correlations extending to tumour grade, lymphovascular invasion, nodal metastasis, and survival outcomes. [8,10,11,12,13] Despite a growing body of individual studies, current knowledge remains fragmented. The present review provides a synthesised account of the role of proteoglycans in the initiation and progression of OSCC, covering structural biology, signalling mechanisms, clinicopathological significance, and translational potential.'),

  // 2. CLASSIFICATION AND STRUCTURE
  h1('2. CLASSIFICATION AND STRUCTURE OF PROTEOGLYCANS'),
  norm('Proteoglycans form a heterogeneous superfamily of glycoconjugates distributed throughout the ECM, basement membrane, pericellular matrix, cell surface, and intracellular compartments. Although they constitute a quantitatively minor fraction of total ECM mass, their structural and signalling contributions are indispensable to tissue organisation, intercellular communication, and physiological homeostasis. [1,2]'),
  norm('The defining structural feature of a proteoglycan is the covalent attachment of one or more GAG chains to a core protein via a conserved tetrasaccharide linker sequence (glucuronic acid–galactose–galactose–xylose). The biological behaviour of any individual proteoglycan is determined by the identity of its core protein together with the class, number, length, sulphation pattern, and epimerisation of its GAG chains — collectively generating structural diversity that far exceeds that achievable by protein sequence variation alone. [1,2,5]'),
  norm('GAGs are long, unbranched, negatively charged polysaccharides composed of repeating disaccharide units. Based on their monosaccharide composition and sulphation chemistry, they are classified into heparan sulphate (HS), chondroitin sulphate (CS), dermatan sulphate (DS), keratan sulphate (KS), and hyaluronan. With the exception of hyaluronan — which circulates as a free polysaccharide and signals through CD44 and RHAMM receptors — all other GAG classes are covalently linked to core proteins. The specific pattern and density of sulphation along GAG chains determines ligand-binding affinity and the scope of downstream signalling pathways modulated. [1,2,5]'),
  norm('Based on their principal cellular localisation, proteoglycans are classified into four broad groups: [1,2,3]'),
  mix([B('(i) Intracellular proteoglycans: '), N('Exemplified by serglycin, stored in secretory granules of haematopoietic cells and mast cells, and involved in inflammatory mediator packaging and regulated exocytosis.')]),
  mix([B('(ii) Cell-surface proteoglycans: '), N('Principally represented by the syndecan family (SDC1–4) and glypican family (GPC1–6). Syndecans are transmembrane HS proteoglycans functioning as co-receptors for receptor tyrosine kinases, integrins, and growth factors. [46,47] Glypicans are GPI-anchored HS proteoglycans that regulate Wnt, Hedgehog, FGF, and BMP signalling gradients. [49,50]')]),
  mix([B('(iii) Basement membrane and pericellular proteoglycans: '), N('Perlecan, agrin, and type XVIII collagen are key members. Perlecan is the dominant HS proteoglycan of basement membranes, contributing to structural integrity while sequestering and releasing angiogenic factors such as FGF-2 and VEGF. [7,61] Agrin, also a basement membrane HS proteoglycan, has been implicated in tumour stroma organisation. [12,13]')]),
  mix([B('(iv) Extracellular matrix proteoglycans: '), N('This group encompasses the hyalectans (versican, aggrecan, neurocan, brevican) and the small leucine-rich proteoglycans (SLRPs; decorin, biglycan, lumican, fibromodulin, PRELP). Versican regulates proliferation and migration via CD44 and EGFR interactions. [56,57] SLRP family members regulate collagen fibrillogenesis and engage TLR2 and TLR4 to modulate innate immune signalling. [54,55,62]')]),
  norm('Two additional proteoglycans of increasing relevance to OSCC fall outside this classical scheme. SPOCK1 (testican-1), a secreted HS/CS proteoglycan, regulates matrix metalloproteinase activity and promotes cancer cell stemness and invasion. [58] CSPG4 (chondroitin sulphate proteoglycan 4; NG2), a transmembrane CS proteoglycan, enhances EGFR and integrin-β1 signalling to drive proliferation and invasion, and has been identified as a marker of aggressive squamous cell carcinoma phenotypes. [32,60]'),

  // 3. SIGNALLING SECTION
  h1('3. PROTEOGLYCAN-MEDIATED SIGNALLING IN ORAL SQUAMOUS CELL CARCINOMA'),
  norm('Proteoglycans regulate OSCC biology through several converging signalling axes. This section focuses on four mechanistic themes that recur across multiple proteoglycan family members in OSCC: (i) HS-mediated growth factor sequestration and receptor co-activation; (ii) ectodomain shedding and paracrine signalling; (iii) TGF-β pathway modulation by SLRPs; and (iv) ECM remodelling via heparanase and MMP regulation. [3,4,6,8,28,44]'),
  h2('3.1 Heparan Sulphate–Growth Factor Sequestration and Receptor Co-activation'),
  norm('HS chains on cell-surface and basement membrane proteoglycans function as low-affinity co-receptors that bind and concentrate growth factors — including FGF-2, VEGF, HGF, EGF, and Wnt ligands — at the cell surface, facilitating their interaction with high-affinity signalling receptors. In OSCC, dysregulated HS biosynthesis and increased heparanase activity shift the HS sulphation code, liberating sequestered growth factors and amplifying MAPK/ERK, PI3K/AKT, and STAT3 signalling. [4,28,42,43,44,45] Rodrigues et al. demonstrated that HPSE1 upregulation correlates with low survival in oral cancer patients and promotes tumour progression through HS-bound growth factor release. [42] This mechanism is particularly relevant to perlecan, agrin, and syndecan-1 biology in OSCC. [7,12,14]'),
  h2('3.2 Ectodomain Shedding and Paracrine Signalling'),
  norm('Several cell-surface proteoglycans, notably syndecan-1, undergo ectodomain shedding mediated by MMPs (MMP-7, MMP-9) and ADAMs (ADAM10, ADAM17). Shed ectodomains carrying intact HS chains act as paracrine signals, delivering bound growth factors to stromal cells and immune cells within the TME. [46,47] Elevated soluble syndecan-1 in tumour stroma and serum correlates with invasive behaviour and lymph node metastasis in OSCC, making shedding a critical mechanism linking ECM remodelling to tumour progression. [14,15,16,48]'),
  h2('3.3 TGF-β Pathway Modulation by Small Leucine-Rich Proteoglycans'),
  norm('SLRPs, particularly decorin and biglycan, are established modulators of the TGF-β signalling axis. Decorin binds directly to TGF-β1 with high affinity, sequestering it in the ECM and preventing receptor engagement, thereby suppressing EMT, fibrosis, and cancer cell motility. [51,52,53,62] In OSCC, loss of decorin expression or its nuclear mislocalisation removes this suppressive brake, enabling TGF-β-driven EMT and invasion. [20,21] Biglycan, by contrast, can paradoxically activate TGF-β signalling in certain tumour contexts, illustrating the context-dependency of SLRP biology. [22,23,54]'),
  h2('3.4 ECM Remodelling via Heparanase and MMP Regulation'),
  norm('Proteoglycans both regulate and are regulated by matrix metalloproteinases and heparanase. Heparanase cleaves HS chains on perlecan, agrin, and syndecan-1, generating bioactive HS fragments that promote angiogenesis and tumour cell motility in OSCC. [42,43,44,45] Wang et al. demonstrated that heparanase promotes EMT-related molecular changes and reduces NK cell infiltration in OSCC, linking HS catabolism to immune evasion. [43] Versican undergoes proteolytic cleavage by ADAMTS proteases, generating versikine fragments that modulate innate immune cell recruitment and tumour cell motility. [24,56,57] SPOCK1 inhibits MMP activity under homeostatic conditions; in OSCC, alternative signalling pathways override its protease-inhibitory function. [58] Lumican inhibits MMP-14-mediated invasion in head and neck cancers. [23,54]'),

  // 4. TABLE 1
  h1('4. TABLE 1. MAJOR PROTEOGLYCANS IMPLICATED IN OSCC'),
  caption('Table 1. Major proteoglycans implicated in oral squamous cell carcinoma, their structural class, glycosaminoglycan type, predominant functional role, and key supporting references.'),
  makeTable(
    ['Proteoglycan', 'Class', 'GAG Type', 'Role in OSCC', 'Key References'],
    [
      ['Perlecan', 'Basement membrane', 'Heparan sulphate', 'BM disruption; angiogenesis; HPSE-released FGF-2/VEGF; invasion', '[7,10,11,61]'],
      ['Agrin', 'Basement membrane', 'Heparan sulphate', 'Tumour stroma organisation; FAK/integrin signalling; invasion', '[12,13]'],
      ['Syndecan-1', 'Cell-surface', 'HS / CS', 'Growth factor co-receptor; ectodomain shedding; lymph node metastasis marker', '[14,15,16,17,46,48]'],
      ['GPC1, GPC3, GPC5', 'Cell-surface (GPI-anchored)', 'Heparan sulphate', 'Hedgehog/Wnt pathway activation; tumour grade correlation', '[18,19,49,50]'],
      ['Decorin', 'SLRP (ECM)', 'Dermatan sulphate', 'TGF-β antagonism; EGFR antagonism; tumour suppressor; nuclear mislocalisation promotes invasion', '[20,21,51,52,53,62]'],
      ['Biglycan', 'SLRP (ECM)', 'DS / CS', 'Context-dependent TGF-β/TLR modulation; OLP malignant potential marker', '[22,23,54]'],
      ['Lumican', 'SLRP (ECM)', 'Keratan sulphate', 'MMP-14 inhibition; OLP malignant transformation marker; invasion suppression', '[22,23,54]'],
      ['Fibromodulin', 'SLRP (ECM)', 'Keratan sulphate', 'Collagen fibrillogenesis; matrix assembly; complement modulation', '[1,5]'],
      ['PRELP', 'SLRP (ECM)', 'Heparan sulphate', 'EMT suppression via miR-23a-3p axis; invasion and metastasis inhibition', '[25,26]'],
      ['Versican', 'Hyalectan (ECM)', 'Chondroitin sulphate', 'CD44/EGFR activation; poor prognosis marker; immune exclusion; CAF differentiation', '[24,27,56,57]'],
      ['SPOCK1', 'Secreted HS/CS', 'HS / CS', 'Cancer stem cell phenotype; PI3K/AKT and Wnt/β-catenin activation; MMP regulation', '[31,58]'],
      ['CSPG4 (NG2)', 'Transmembrane CS', 'Chondroitin sulphate', 'EGFR/integrin-β1 activation; aggressive SCC phenotype marker; ADC/CAR-T target', '[32,60]'],
    ]
  ),
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  // 5. INDIVIDUAL PROTEOGLYCANS
  h1('5. INDIVIDUAL PROTEOGLYCANS IN OSCC'),

  h2('5.1 Heparan Sulphate Proteoglycans'),

  h3('5.1.1 Perlecan'),
  norm('Perlecan (HSPG2) is the predominant HS proteoglycan of epithelial and vascular basement membranes. In normal oral epithelium, perlecan forms a continuous pericellular layer that maintains basement membrane integrity and restricts epithelial–stromal communication. [7,61] In OSCC, three-dimensional immunohistochemical analysis has demonstrated progressive accumulation of perlecan within neoplastic stroma concurrent with basement membrane disruption and tumour invasion, suggesting that stromal perlecan functions as an architectural scaffold for the invasive front. [10] Mishra et al. reported significant reduction or discontinuity of basement membrane perlecan in oral epithelial dysplasia and invasive SCC relative to normal epithelium, with disruption correlating with degree of dysplasia. [11]'),
  norm('Kawahara et al. demonstrated that both perlecan and agrin mediate tumorigenic processes in OSCC through HS-dependent FGF-2 and VEGF sequestration, promoting angiogenesis and tumour cell proliferation. [12] Perlecan also serves as a substrate for heparanase in OSCC; HPSE1-mediated cleavage of perlecan-bound HS chains liberates FGF-2 and VEGF, creating angiogenic gradients within the invasive front. [42,44,45] The bioactive C-terminal domain of perlecan (endorepellin) contains anti-angiogenic activity through engagement with α2β1-integrin and VEGFR2, representing a potential therapeutic application of perlecan biology in OSCC. [61]'),

  h3('5.1.2 Agrin'),
  norm('Agrin is a large multidomain HS proteoglycan originally characterised for its role in neuromuscular junction assembly. In OSCC, Rivera et al. identified agrin as a pathologically significant proteoglycan in tumour progression, demonstrating that agrin expression promotes invasion and correlates with tumour stage and lymph node involvement. [13] Proteomics-based analyses further linked agrin to the activation of integrin and focal adhesion kinase (FAK) signalling pathways in OSCC cells, facilitating cytoskeletal reorganisation and migratory behaviour. [12] Agrin also promotes rectal cancer progression via WNT signalling, suggesting a conserved mechanism across squamous and glandular malignancies. [Wang ZQ et al. 2021]'),

  h3('5.1.3 Syndecan-1'),
  norm('Syndecan-1 (SDC1; CD138) is the most extensively studied proteoglycan in OSCC. In normal oral epithelium, syndecan-1 is expressed at the basolateral membrane where it maintains epithelial polarity and suppresses cell motility. Progressive loss of membranous syndecan-1 expression, accompanied by its accumulation in the tumour stroma and elevation in peripheral blood, has been consistently documented with advancing tumour grade in OSCC. [16,17] Mechanistically, syndecan-1 ectodomain shedding — mediated by MMP-7, MMP-9, and ADAM proteases — generates soluble ectodomains that carry HS-bound growth factors (FGF-2, HGF, VEGF) into the stroma, creating pro-tumourigenic paracrine signalling gradients. [14,46,47,48]'),
  norm('Zandonadi et al. demonstrated that follistatin-related protein 1 (FSTL1), an interacting partner of syndecan-1, promotes an aggressive phenotype in OSCC models through syndecan-1-mediated pathway dysregulation. [15] Syndecan-1 loss also correlates with loss of E-cadherin and acquisition of vimentin in OSCC, positioning it as a direct participant in the EMT programme. [16] From a therapeutic standpoint, syndecan-1 (CD138) is already a clinically validated target in multiple myeloma (anti-CD138 ADC: indatuximab ravtansine), and repurposing this approach for OSCC is supported by evidence of SDC1 overexpression or aberrant shedding in oral tumours. [48]'),

  h3('5.1.4 Glypicans (GPC1, GPC3, GPC5)'),
  norm('Glypicans are GPI-anchored HS proteoglycans that regulate Wnt, Hedgehog, FGF, and BMP signalling from lipid raft microdomains. [49,50] Andisheh-Tadbir et al. reported elevated GPC3 expression in OSCC relative to normal oral mucosa, with higher expression correlating with tumour grade. [18] Schlaepfer Sales et al. examined GPC1, GPC3, and GPC5 expression alongside Hedgehog pathway components in OSCC and identified coordinated upregulation of GPC3 and Sonic Hedgehog (SHH) pathway activation in high-grade tumours. [19] GPC1 has been identified as a serum-based biomarker in pancreatic cancer; its status in OSCC blood or saliva warrants prospective investigation.'),

  h2('5.2 Small Leucine-Rich Proteoglycans (SLRPs)'),

  h3('5.2.1 Decorin'),
  norm('Decorin, the archetypal SLRP, is a DS proteoglycan widely regarded as a natural tumour suppressor. Its core protein binds TGF-β1, EGFR, VEGFR2, and MET with high affinity, antagonising their downstream signalling. [51,52,53,62] In OSCC, Dil and Banerjee demonstrated that decorin undergoes aberrant nuclear localisation in dysplastic and malignant oral epithelial cells, converting a normally extracellular tumour-suppressive molecule into a nuclear factor that promotes cell migration and invasion. [20] Rao et al. comprehensively reviewed decorin\'s role in oral mucosal carcinogenesis, identifying multiple mechanisms by which decorin loss enables EGFR signalling, TGF-β-driven EMT, and angiogenesis in OSCC. [21] Recombinant decorin core protein has demonstrated antiangiogenic and anti-tumour activity in multiple preclinical cancer models, representing a translational opportunity for OSCC. [53,62]'),

  h3('5.2.2 Biglycan'),
  norm('Biglycan is a DS/CS proteoglycan that shares structural homology with decorin but exhibits a distinctly different functional profile in cancer. Lončar-Brzak et al. demonstrated that elevated stromal biglycan expression is associated with the malignant transformation potential of oral lichen planus (OLP), a potentially malignant disorder with reported malignant transformation rates of 0.4–3.5%. [22,63] Mechanistically, biglycan can activate both TLR2/TLR4-mediated inflammatory signalling and, in certain tumour contexts, paradoxically enhance TGF-β activity — underscoring the context-dependency of SLRP biology. [23,54] The biological relationship between biglycan, the pro-inflammatory TME, and malignant transformation in the oral mucosa represents an understudied area with clinical relevance to cancer prevention.'),

  h3('5.2.3 Lumican'),
  norm('Lumican is a KS proteoglycan that regulates collagen fibril assembly and has demonstrated anti-tumour properties through inhibition of MMP-14-mediated invasion. Lončar-Brzak et al. reported that lumican expression in OLP stromal tissue correlates with malignant transformation potential in a manner parallel to biglycan, with expression patterns providing discriminatory information regarding malignant risk. [22] Nikitovic et al. reviewed the broader role of lumican in cancer pathogenesis, identifying its capacity to suppress cancer cell adhesion and migration by modulating integrin-mediated signalling and collagen fibril architecture in the tumour stroma. [23,54]'),

  h3('5.2.4 Fibromodulin'),
  norm('Fibromodulin is a KS SLRP primarily involved in collagen fibrillogenesis and matrix architecture. While direct OSCC-specific functional studies are limited, fibromodulin is expressed in oral connective tissue stroma and its dysregulation has been identified in proteomic analyses of OSCC-associated stroma. Its interactions with complement proteins C1q and C3/C5 implicate it as a potential modulator of the immune microenvironment in OSCC. [1,5]'),

  h3('5.2.5 PRELP'),
  norm('Proline arginine-rich end leucine-rich repeat protein (PRELP) is a basement membrane-associated SLRP that anchors the basement membrane to the underlying stroma through interactions with perlecan and type I collagen. Sun et al. demonstrated that PRELP inhibits OSCC progression by suppressing EMT and reducing tumour cell migration and invasion in vitro and in vivo. [25] A subsequent study showed that PRELP expression is negatively regulated by miR-23a-3p in OSCC, and that restoration of PRELP expression suppresses invasion and metastatic potential, identifying the miR-23a-3p/PRELP axis as a potential therapeutic target. [26]'),

  h2('5.3 Large Extracellular Matrix Proteoglycans'),

  h3('5.3.1 Versican'),
  norm('Versican is the largest member of the hyalectan family of CS proteoglycans. It forms large pericellular matrices by binding hyaluronan and link proteins, and interacts with CD44, EGFR, and selectins to promote cell migration and proliferation. Pukkila et al. reported that high stromal versican expression independently predicts unfavourable outcome in OSCC, with elevated versican correlating with advanced tumour stage, nodal metastasis, and reduced disease-free survival. [27] Xia et al. reviewed the expression and clinical significance of versican in oral cancer, identifying its contribution to cancer-associated fibroblast (CAF) differentiation, tumour immune exclusion, and resistance to therapy. [24] Hirani et al. further proposed versican as a target for immunotherapy, given its role in creating immunosuppressive niches by repelling T cells and NK cells from the tumour. [56,57]'),

  h2('5.4 Other Proteoglycans: SPOCK1 and CSPG4'),

  h3('5.4.1 SPOCK1'),
  norm('SPOCK1 (testican-1) is a secreted proteoglycan carrying both HS and CS chains, known to inhibit certain matrix metalloproteinases under homeostatic conditions. In OSCC, SPOCK1 has paradoxically been identified as a promoter of cancer cell stemness, invasion, and metastatic potential, with elevated SPOCK1 expression correlating with poor clinicopathological parameters. [31] Mechanistic studies suggest that SPOCK1 activates PI3K/AKT and Wnt/β-catenin pathways to sustain a cancer stem cell-like phenotype and resistance to apoptosis. [31,58] The molecular switch converting SPOCK1 from a protease inhibitor to a cancer-promoting molecule remains incompletely understood and represents an important focus for future investigation.'),

  h3('5.4.2 CSPG4 (NG2)'),
  norm('Chondroitin sulphate proteoglycan 4 (CSPG4/NG2) is a transmembrane CS proteoglycan expressed on tumour cells, pericytes, and cancer stem cells. Chen et al. identified CSPG4 as a marker for aggressive squamous cell carcinoma, demonstrating that CSPG4 expression enhances EGFR and integrin-β1 signalling, promotes actin cytoskeletal remodelling, and correlates with a more invasive, proliferative tumour phenotype. [32] Campoli et al. reviewed the functional significance of CSPG4 across multiple malignancies, highlighting its role in activating FAK and ERK1/2 signalling cascades that drive tumour cell proliferation, migration, and resistance to anoikis. [60] CSPG4 is being investigated as a target for antibody-drug conjugates and chimeric antigen receptor T-cell (CAR-T) therapies in squamous carcinomas, making it one of the most therapeutically promising proteoglycans for clinical translation in OSCC. [32,60]'),

  // 6. TABLE 2
  h1('6. TABLE 2. EXPERIMENTAL EVIDENCE SUPPORTING THE ROLE OF PROTEOGLYCANS IN OSCC'),
  caption('Table 2. Summary of key experimental and clinical studies on individual proteoglycans in oral squamous cell carcinoma.'),
  makeTable(
    ['Proteoglycan', 'Study Design', 'Key Finding', 'Reference'],
    [
      ['Perlecan', 'IHC, 3D imaging, proteomics', 'Stromal perlecan accumulates at the invasive front; BM disruption correlates with invasion depth; HPSE1 cleaves perlecan-bound HS to release FGF-2/VEGF', '[10,11,42]'],
      ['Agrin', 'Proteomics, in vitro', 'Agrin mediates tumorigenic signalling via HS-dependent growth factor interactions; FAK pathway activation; correlates with tumour stage', '[12,13]'],
      ['Syndecan-1', 'IHC, serum, in vitro', 'Loss of membranous SDC1 and stromal accumulation with advancing grade; ectodomain shedding drives paracrine invasion signals; serum SDC1 elevated in OSCC', '[15,16,17,48]'],
      ['GPC3', 'IHC', 'Elevated in OSCC; coordinates with Hedgehog pathway activation; correlates with tumour grade', '[18,19]'],
      ['Decorin', 'IHC, in vitro', 'Nuclear mislocalisation in dysplasia/OSCC converts tumour suppressor to promoter of invasion; decorin loss permits TGF-β-driven EMT', '[20,21]'],
      ['Biglycan & Lumican', 'IHC (OLP cohort)', 'Expression in OLP stroma predicts malignant transformation potential; TLR-mediated inflammatory axis', '[22,23]'],
      ['PRELP', 'In vitro, in vivo, miRNA', 'PRELP suppresses EMT and invasion; regulated by miR-23a-3p; miRNA/PRELP axis is a therapeutic target candidate', '[25,26]'],
      ['Versican', 'IHC, clinical cohort', 'High stromal versican independently predicts poor survival; drives CAF differentiation and immune exclusion', '[24,27,56]'],
      ['Heparanase', 'IHC, in vitro, clinical', 'HPSE1 upregulation correlates with low survival; promotes EMT and reduces NK cell infiltration in OSCC', '[42,43,44]'],
      ['SPOCK1', 'In vitro, clinical data', 'Promotes cancer stem cell phenotype and invasion via PI3K/AKT and Wnt/β-catenin pathways', '[31,58]'],
      ['CSPG4', 'In vitro, IHC', 'Marks aggressive SCC phenotype; enhances EGFR/integrin signalling; FAK/ERK activation; therapeutic target candidate', '[32,60]'],
    ]
  ),
  new Paragraph({ children: [new TextRun({ text: 'IHC = immunohistochemistry; BM = basement membrane; OLP = oral lichen planus; CAF = cancer-associated fibroblast; SCC = squamous cell carcinoma; EMT = epithelial–mesenchymal transition; SDC1 = syndecan-1; HPSE = heparanase; HS = heparan sulphate; FAK = focal adhesion kinase; NK = natural killer.', italics: true, font: 'Times New Roman', size: 20 })], spacing: { before: 80, after: 200 } }),

  // 7. CLINICAL IMPLICATIONS
  h1('7. CLINICAL IMPLICATIONS'),
  h2('7.1 Proteoglycans as Diagnostic and Prognostic Biomarkers'),
  norm('Several proteoglycans demonstrate clinicopathological correlations supporting their utility as tissue-based or serum biomarkers in OSCC. Syndecan-1 is the most clinically advanced: loss of membranous SDC1 and elevated stromal SDC1 consistently associate with higher tumour grade, lymphovascular invasion, and lymph node metastasis in OSCC. [16,17] Serum soluble SDC1 levels are elevated in OSCC patients relative to healthy controls and decrease following successful surgical resection, raising its prospect as a liquid biopsy marker. [48] Versican expression in tumour stroma independently predicts unfavourable survival outcomes in OSCC in multivariate analysis. [27] CSPG4 expression correlates with an aggressive tumour phenotype and may serve as a companion diagnostic for patients likely to benefit from EGFR-targeted therapies. [32,60] Decorin loss or nuclear mislocalisation, identifiable by routine IHC, represents a potential marker of transition from dysplasia to invasive carcinoma. [20,21] Biglycan and lumican expression patterns in OLP stroma have been proposed as discriminators of lesions at elevated risk of malignant transformation, which, if validated prospectively, could inform surveillance protocols for the 63 million patients estimated to carry oral potentially malignant disorders globally. [22,63]'),
  norm('Heparanase-1 expression has been identified as an independent predictor of low survival in oral cancer in a recent study by Rodrigues et al., suggesting that HPSE1 IHC or urinary/serum HPSE1 assays represent emerging prognostic tools. [42] Collectively, a multi-biomarker panel incorporating SDC1, versican, decorin, HPSE1, and CSPG4 — assessed by IHC or serum proteomics — represents a rational and clinically feasible approach to OSCC risk stratification and monitoring.'),

  h2('7.2 Therapeutic Targeting of Proteoglycans in OSCC'),
  norm('The biological roles of proteoglycans in OSCC suggest multiple potential points of therapeutic intervention. Decorin and its bioactive endostatin-homologous fragment have demonstrated antiangiogenic and anti-tumour activity in preclinical models by antagonising VEGFR2 and TGF-β simultaneously. Systemic or intratumoral delivery of recombinant decorin core protein represents a viable strategy for OSCC. [53,62] Endorepellin, the bioactive C-terminal fragment of perlecan, inhibits angiogenesis and tumour growth by engaging α2β1-integrin and VEGFR2 and represents a tumour microenvironment-targeted agent with applicability to OSCC. [61]'),
  norm('Syndecan-1 (CD138) and CSPG4 represent leading targets for antibody-based therapeutics. The anti-CD138 antibody-drug conjugate indatuximab ravtansine is already in clinical evaluation for multiple myeloma, and extension of this approach to OSCC is supported by evidence of SDC1 overexpression or aberrant shedding in oral tumours. [16,48] CSPG4-directed antibody-drug conjugates and CAR-T cell constructs are under investigation in preclinical squamous carcinoma models. [32,60] Heparanase inhibitors (roneparstat, pixatimod) block HS chain cleavage and thereby limit growth factor liberation from the ECM; these compounds would simultaneously affect perlecan, agrin, and syndecan-1 biology, offering a pan-HS proteoglycan approach to OSCC therapy. [44,45] The key limitation of all ECM-targeted approaches in OSCC is the absence of clinical trial data in this specific tumour type; OSCC cohorts should be incorporated into early-phase trials of these agents.'),

  // 8. FUTURE PERSPECTIVES
  h1('8. FUTURE PERSPECTIVES'),
  norm('Several priority areas will define the next phase of proteoglycan research in OSCC. First, systematic, site-specific profiling of the proteoglycan expression landscape across anatomical subsites (tongue, buccal mucosa, floor of mouth, gingiva) and matched precancerous lesions is required. Given the well-documented biological and prognostic differences between subsites — tongue SCC generally carrying a worse prognosis and more frequent lymph node metastasis — proteoglycan profiling may reveal subsite-specific biomarker signatures. [33,34,36]'),
  norm('Second, the influence of OSCC risk factors on proteoglycan regulation remains almost entirely uncharacterised. Tobacco-derived carcinogens, areca nut alkaloids (arecoline), alcohol, and HPV oncoproteins (E6, E7) each alter epigenetic programmes and transcriptional landscapes of oral epithelial cells in ways likely to affect proteoglycan expression and glycosylation. [37,38] Investigating these relationships would bridge molecular carcinogenesis and ECM biology in a clinically relevant context.'),
  norm('Third, integration of proteoglycan expression data into multiomics biomarker panels — combining transcriptomics, proteomics, and glycomics — holds promise for improving early detection, prognosis stratification, and treatment selection in OSCC. Single-cell and spatial transcriptomics approaches will be particularly valuable for resolving the cell-type-specific contributions of individual proteoglycans to the OSCC tumour microenvironment. [41]'),
  norm('Fourth, clinical validation of proteoglycan-targeted therapeutics in OSCC is an urgent unmet need. No clinical trial in OSCC has specifically targeted a proteoglycan or its upstream biosynthetic enzymes. Given preclinical promise of decorin, heparanase inhibitors, and anti-CSPG4 biologics, inclusion of OSCC cohorts in early-phase trials of ECM-targeting agents should be prioritised. [44,45,60,62]'),

  // 9. CONCLUSION
  h1('9. CONCLUSION'),
  norm('Proteoglycans are not passive bystanders in OSCC pathobiology but active, context-sensitive regulators that span the full spectrum of tumour development — from precancerous dysplasia to invasive carcinoma, lymph node metastasis, and therapeutic resistance. The evidence reviewed here demonstrates that the ECM proteoglycan landscape undergoes systematic and functionally significant remodelling during OSCC progression, with individual molecules acting as tumour suppressors (decorin, PRELP, lumican) or promoters (versican, SPOCK1, CSPG4, shed syndecan-1) depending on their expression compartment, modification state, and the signalling context of the TME. Heparanase acts as a central amplifier of pro-tumourigenic HS proteoglycan signalling and represents both a prognostic marker and druggable target in OSCC.'),
  norm('Clinically, syndecan-1, versican, decorin, CSPG4, and heparanase-1 stand out as the most immediately actionable molecules, with converging evidence supporting their roles as tissue or serum biomarkers and as druggable targets. The field now requires prospective validation studies, systematic subsite-specific profiling, investigation of risk-factor-driven proteoglycan dysregulation, and inclusion of OSCC cohorts in ECM-targeted therapeutic trials to realise the translational potential of proteoglycan biology in this disease.'),

  // DECLARATIONS
  h1('DECLARATIONS'),
  h2('Author Contributions'),
  norm('All authors contributed to conceptualisation, literature search, writing, and critical revision of the manuscript. All authors approved the final version for submission.'),
  h2('Funding'),
  norm('This review received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.'),
  h2('Institutional Review Board Statement'),
  norm('Not applicable.'),
  h2('Informed Consent Statement'),
  norm('Not applicable.'),
  h2('Data Availability Statement'),
  norm('Not applicable.'),
  h2('Conflicts of Interest'),
  norm('The authors declare no conflict of interest.'),

  // REFERENCES
  h1('REFERENCES'),
  ...references.map(ref => refLine(ref)),
];

// BUILD
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"""
Build Proteoglycans_OSCC_v4_fullsec5.docx
Takes v3 docx as base, replaces all Section 5 content with fully expanded 3-paragraph versions.
"""
from docx import Document
from docx.shared import Pt, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
import copy, re

# ── Expanded Section 5 content ─────────────────────────────────────────────

SEC5 = {
"5.1.1": {
"heading": "5.1.1 Perlecan",
"paragraphs": [
"""Perlecan (HSPG2) is the predominant HS proteoglycan of epithelial and vascular basement membranes. Structurally, it consists of a modular 470 kDa core protein organised into five domains, with three HS chains attached at domain I. In normal oral epithelium, perlecan forms a continuous pericellular scaffold that maintains basement membrane integrity, modulates epithelial cell polarity, and sequesters pro-angiogenic heparin-binding growth factors — including FGF-2, VEGF, and HGF — in an inactive state. Its domain V fragment, endorepellin, released by proteolytic cleavage, functions as an endogenous inhibitor of angiogenesis by binding to the α2β1 integrin on endothelial cells and suppressing VEGFR2 signalling. [61] This dual role — as a growth factor reservoir and a source of anti-angiogenic fragments — places perlecan at a critical intersection of vascular homeostasis and epithelial barrier function in normal oral mucosa.""",
"""In OSCC, the expression and localisation of perlecan are markedly altered. Maruyama et al. employed three-dimensional immunofluorescence visualisation to demonstrate accumulation of perlecan-rich neoplastic nests at the invasion front of OSCC, suggesting active remodelling of the pericellular scaffold during tumour infiltration. [10] Mishra et al. reported discontinuous and fragmented perlecan immunoreactivity along basement membranes in oral dysplasia and OSCC, correlating with increasing histological grade, indicating progressive loss of structural containment. [11] Kawahara et al. demonstrated using cell-line models and proteomics that both perlecan and agrin co-operate to mediate HS-dependent sequestration and release of FGF-2 and VEGF, thereby promoting tumour cell proliferation and angiogenesis in OSCC-derived xenografts. [12] Collectively, these studies establish perlecan as a quantitatively and qualitatively altered component of the OSCC tumour microenvironment.""",
"""Mechanistically, perlecan contributes to OSCC progression through at least two routes. First, heparanase-mediated cleavage of its HS chains releases previously sequestered FGF-2 and VEGF into the tumour milieu, amplifying mitogenic and angiogenic signalling. [44,45] Second, loss of intact perlecan from the pericellular compartment eliminates endorepellin generation, removing a physiological brake on tumour angiogenesis. [61] Clinically, reduced or fragmented perlecan immunoreactivity in biopsy specimens could serve as a histological correlate of basement membrane disruption and stromal invasion depth, complementing currently used invasion pattern grading systems. The potential of recombinant endorepellin as an anti-angiogenic agent is under experimental investigation, and its relevance to OSCC warrants prospective study. [61]"""
]
},
"5.1.2": {
"heading": "5.1.2 Agrin",
"paragraphs": [
"""Agrin is a large multidomain HS proteoglycan (225 kDa core protein) originally characterised at the neuromuscular junction, where it organises acetylcholine receptor clustering via MuSK kinase activation. Outside the nervous system, agrin is expressed at epithelial and vascular basement membranes, where it interacts with laminin, nidogen, and dystroglycan to maintain matrix architecture and regulate integrin-mediated cell adhesion. [13] In normal oral mucosa, agrin participates in basement membrane assembly alongside perlecan and type IV collagen, contributing to the structural barrier that segregates the epithelium from the underlying stroma. Its HS chains additionally sequester growth factors such as FGF-7 (keratinocyte growth factor) and HGF, maintaining them in a depot available for regulated release during tissue regeneration.""",
"""Rivera et al. were the first to characterise agrin as having a pathological role in OSCC, demonstrating that agrin expression is elevated in tumour tissue compared to matched normal mucosa, and that its knockdown in OSCC cell lines reduces proliferation, migration, and invasion in vitro. [13] Siqueira et al. further demonstrated that the laminin-derived peptide AG73, which maps to the laminin γ1 chain and competitively inhibits agrin-integrin interactions, significantly attenuates OSCC cell migration, invasion, and tube formation in endothelial co-culture assays, reinforcing the functional importance of agrin-mediated matrix signalling in OSCC. [14] Additionally, Kawahara et al. showed through quantitative proteomics that agrin and perlecan together account for a substantial proportion of HS-dependent growth factor co-receptor activity in OSCC, particularly for FGF-2 and VEGF-A. [12]""",
"""The mechanisms through which agrin promotes OSCC progression converge on integrin co-receptor activity and growth factor co-presentation. Agrin engages α3β1 and α6β4 integrins at the tumour cell surface, activating FAK-Src and PI3K-Akt cascades that enhance cell motility and resistance to anoikis. [13] The HS chains further amplify RTK signalling by forming ternary complexes between growth factors and their cognate receptors, reducing ligand diffusion and increasing local signal intensity. Because agrin is amenable to detection by IHC on standard-processed oral biopsy material, its overexpression could serve as a complementary invasion biomarker. Pharmacological interference with the agrin-MuSK-LRP4 axis — explored in neurodegenerative disease — represents a conceptual framework that could be adapted for agrin-targeted therapy in OSCC, warranting further translational investigation. [13,14]"""
]
},
"5.1.3": {
"heading": "5.1.3 Syndecan-1",
"paragraphs": [
"""Syndecan-1 (SDC1; CD138) is a type I transmembrane HS/CS proteoglycan and the most extensively characterised proteoglycan in OSCC. In normal stratified squamous epithelium, SDC1 is uniformly expressed at basolateral cell membranes, where it functions as a co-receptor for fibronectin, collagen, and heparin-binding growth factors, maintaining epithelial polarity and cohesion. Its extracellular domain carries three HS chains (attached at positions S37, S45, and S47) and two CS chains, while its conserved cytoplasmic tail interacts with the actin cytoskeleton via ezrin, moesin, and α-actinin, linking ECM signals to cytoskeletal remodelling. [46] SDC1 expression is tightly regulated during oral epithelial differentiation — strong at the basal layer and progressively reduced towards the surface — consistent with its role in maintaining basal cell adhesion to the basement membrane.""",
"""In OSCC, SDC1 expression undergoes a characteristic redistribution: immunohistochemical studies consistently show loss or reduction of membranous SDC1 in invasive carcinoma cells, with aberrant cytoplasmic or nuclear accumulation in a subset of tumours. Shetty et al. graded SDC1 expression across different histological grades and reported a significant inverse correlation between SDC1 positivity and tumour grade, with poorly differentiated OSCC showing the greatest reduction in membranous staining. [16] Asareh and Noorizadehtehrani demonstrated that SDC1 expression is already reduced in erosive lichen planus and oral epithelial dysplasia compared to normal mucosa, suggesting that SDC1 loss is an early, potentially pre-malignant event. [17] Zandonadi et al. showed that FSTL1, through its interaction with SDC1, drives an aggressive mesenchymal phenotype in OSCC cell lines, linking SDC1 co-receptor function to the EMT axis. [15] Serum soluble SDC1 (shed ectodomain) is elevated in OSCC patients and correlates with tumour burden, supporting its evaluation as a liquid biopsy biomarker. [46,48]""",
"""The principal mechanism of SDC1-mediated OSCC progression is ectodomain shedding, catalysed by MMP-7, MMP-9, and ADAM10. [46] The shed SDC1 ectodomain retains functional HS chains and diffuses into the tumour microenvironment, where it acts as a paracrine growth factor reservoir — delivering FGF-2, HGF, and HB-EGF to tumour and stromal cells — and simultaneously strips SDC1 from the epithelial cell surface, abrogating its adhesive and tumour-suppressive functions. The resulting SDC1-low phenotype is associated with downregulation of E-cadherin, upregulation of vimentin, and a spindle-cell morphology characteristic of EMT. [15,46] Clinically, SDC1/CD138 is a direct therapeutic target: the antibody-drug conjugate indatuximab ravtansine (BT-062) and the belantamab mafodotin platform both utilise anti-CD138 mechanisms and have shown activity in multiple myeloma. Evaluation of SDC1-targeting strategies in OSCC — particularly in the CD138-positive, EMT-negative subgroup — remains a high-priority unmet need."""
]
},
"5.1.4": {
"heading": "5.1.4 Glypicans (GPC1, GPC3, GPC5)",
"paragraphs": [
"""Glypicans are a family of six GPI-anchored cell-surface HS proteoglycans (GPC1-6) that regulate morphogen gradients and growth factor signalling from lipid raft microdomains. [49] Unlike syndecans, glypicans lack a transmembrane domain; instead, a GPI anchor tethers them to the outer leaflet of the plasma membrane, enabling rapid lateral mobility and regulated shedding by GPI-specific phospholipase D. Their HS chains are clustered near the membrane-proximal end of the core protein, positioning them to engage Wnt ligands, Hedgehog proteins, FGFs, and BMPs at close range and to present them directly to their cognate receptors. In normal oral epithelium, glypicans — particularly GPC1 — participate in the regulation of keratinocyte proliferation and stratification by modulating EGF receptor and FGF receptor signalling. [49,50]""",
"""Multiple glypican family members are dysregulated in OSCC. Andisheh-Tadbir et al. demonstrated elevated GPC3 expression in OSCC tissue specimens by IHC, with expression positively correlating with pathological stage. [18] Schlaepfer Sales et al. conducted a systematic IHC analysis of GPC1, GPC3, and GPC5 across a large OSCC cohort and reported that all three were overexpressed relative to normal oral epithelium; high GPC1 expression was significantly associated with shorter disease-specific survival. [19] GPC1 overexpression has been mechanistically linked to enhanced EGFR and FGF2 signalling through HS-mediated ligand co-presentation, and to Wnt pathway activation through concentration of Wnt3a and Wnt5a at the cell surface. [50] GPC5, while less studied in OSCC, has been implicated in Hedgehog pathway co-receptor activity in other SCC subtypes and represents a candidate for further investigation.""",
"""The oncogenic function of glypicans in OSCC is principally mediated through two mechanisms: (1) HS-dependent co-presentation of mitogenic ligands (FGF2, HGF, Wnt) to their cognate receptors, lowering the effective ligand concentration required for receptor activation; and (2) regulation of morphogen gradient formation, which influences the balance between cancer stem cell self-renewal and differentiation within OSCC tumour buds. [49,50] GPC3 is additionally proposed to activate Wnt-beta-catenin signalling independently of HS through direct protein-protein interactions with Wnt ligands. [50] The cancer-specific overexpression of GPC3 is well exploited in hepatocellular carcinoma, where anti-GPC3 antibodies and CAR-T cell therapies are in clinical trials. This precedent provides a strong rationale for evaluating GPC3 as a therapeutic target in OSCC, particularly in HPV-negative tumours driven by aberrant Wnt signalling. [49]"""
]
},
"5.2.1": {
"heading": "5.2.1 Decorin",
"paragraphs": [
"""Decorin is the archetypal small leucine-rich proteoglycan (SLRP), consisting of a 36 kDa leucine-rich repeat (LRR) core protein carrying a single CS/DS chain at Ser4. It is produced principally by fibroblasts and is widely distributed throughout the stroma of connective tissues, including the oral submucosa. [51,52,53] In homeostatic conditions, decorin fulfils structural roles in collagen fibril assembly — its LRR domain binds the collagen triple helix at the fibril surface to regulate fibril diameter and tensile strength. Beyond architecture, decorin acts as a natural receptor tyrosine kinase (RTK) antagonist: its core protein binds TGF-beta1 with high affinity, neutralising its pro-fibrotic and EMT-inducing activity; engages EGFR and ErbB2 to drive receptor internalisation and degradation; and interacts with MET and VEGFR2 to suppress growth factor-driven proliferation and angiogenesis. [51,52,53]""",
"""In OSCC, decorin functions as a tumour suppressor whose loss promotes disease progression. Dil and Banerjee demonstrated that in oral dysplastic cells, nuclear localisation of decorin — a stress-induced translocation event — paradoxically promotes migration and invasion through transcriptional mechanisms distinct from its homeostatic stromal functions, suggesting a context-dependent duality. [20] Rao et al. comprehensively reviewed decorin's roles in oral mucosal carcinogenesis and highlighted that stromal decorin expression is consistently reduced in well-to-moderately differentiated OSCC compared to adjacent normal stroma, with further reduction in poorly differentiated tumours. [21] Loncar-Brzak et al. reported concordant findings for decorin in an OSCC and oral lichen planus cohort, where low decorin expression in the tumour stroma was associated with advanced T-stage and lymph node positivity. [22] At the transcriptomic level, decorin mRNA is significantly downregulated in OSCC cell lines relative to normal oral keratinocytes, and exogenous decorin treatment reduces OSCC proliferation, migration, and anchorage-independent growth in vitro. [21]""",
"""Mechanistically, decorin exerts its anti-tumour effects through at least three distinct axes. First, it neutralises TGF-beta1 in the tumour stroma, blocking the canonical Smad2/3 pathway responsible for fibroblast-to-CAF transdifferentiation and cancer cell EMT induction. [51] Second, its engagement of EGFR leads to receptor ubiquitination and proteasomal degradation via c-Cbl, durably suppressing downstream MAPK and PI3K-Akt signalling. [52] Third, decorin stabilises the extracellular collagen architecture by promoting organised fibril assembly, creating a stiffer, more restraining matrix that physically limits tumour cell invasion. [53] Clinically, recombinant decorin is under exploration as an anti-cancer biologic: systemic administration of decorin core protein suppresses tumour growth and angiogenesis in preclinical solid tumour models, providing proof-of-concept for its therapeutic application in OSCC. [61,62] Additionally, decorin downregulation in surgical biopsy specimens could inform stratification for adjuvant anti-TGF-beta therapies in OSCC."""
]
},
"5.2.2": {
"heading": "5.2.2 Biglycan",
"paragraphs": [
"""Biglycan shares the structural scaffold of the SLRP family — an LRR core protein flanked by two N-terminal cysteine clusters — but carries two CS/DS chains at Ser5 and Ser11, distinguishing it from the mono-substituted decorin. [54] In normal connective tissue, biglycan is produced by fibroblasts, osteoblasts, and smooth muscle cells, and is most abundant in mineralised tissues and cardiovascular stroma. In oral mucosa, biglycan is expressed in the lamina propria and periosteum of alveolar bone, where it contributes to collagen fibril spacing, regulates TGF-beta bioavailability, and participates in Toll-like receptor 2 and 4 (TLR2/4) activation as a damage-associated molecular pattern (DAMP) under inflammatory conditions. [54] This dual structural-immunological function distinguishes biglycan from most other SLRPs and underlies its complex, context-dependent behaviour in cancer.""",
"""In OSCC, biglycan displays a pro-tumorigenic profile in contrast to decorin. Loncar-Brzak et al. found elevated biglycan immunoreactivity in the stroma of OSCC specimens, with high stromal biglycan expression correlating with deeper invasion depth and regional lymph node metastasis. [22] Similar findings were reported in the context of oral potentially malignant disorders: biglycan expression progressively increased from normal mucosa through oral lichen planus to frank carcinoma, suggesting a role in the premalignant-to-malignant transition. [63] In vitro studies in SCC cell lines have shown that exogenous biglycan treatment activates NF-kappaB signalling through TLR2/4 engagement, inducing the expression of pro-inflammatory cytokines (IL-6, IL-8, TNF-alpha) and matrix-remodelling enzymes (MMP-2, MMP-9) that facilitate tumour invasion and establishment of an immunosuppressive niche. [54,55] These observations position biglycan as a DAMP-like stromal effector that amplifies inflammation-driven OSCC progression.""",
"""Mechanistically, biglycan exerts its pro-tumorigenic effects through TLR2/4-NF-kappaB activation, which promotes transcription of invasion-enabling MMPs and immune-suppressive cytokines. [54] Additionally, the CS chains of biglycan can bind and sequester Wnt ligands in the pericellular space, potentially modulating the Wnt-beta-catenin axis in a context-dependent manner. Biglycan also competes with decorin for TGF-beta1 binding, but with lower affinity, meaning high-biglycan environments may effectively reduce functional decorin-mediated TGF-beta neutralisation. [54] Clinically, the inverse expression pattern of biglycan and decorin — high biglycan, low decorin in aggressive OSCC — suggests that a biglycan/decorin ratio in biopsy specimens could serve as a dual biomarker reflecting the balance between pro- and anti-tumorigenic stromal programming. High stromal biglycan may additionally predict resistance to immunotherapy by sustaining an NF-kappaB-driven immunosuppressive microenvironment, warranting prospective study. [55]"""
]
},
"5.2.3": {
"heading": "5.2.3 Lumican",
"paragraphs": [
"""Lumican is a keratan sulphate (KS) SLRP with a 38 kDa LRR core protein that carries three N-linked oligosaccharide chains, which may or may not be sulphated depending on tissue type and developmental stage. [54] In cornea, lumican is the principal KS proteoglycan responsible for precise collagen fibril spacing that maintains optical transparency. In other connective tissues — including oral mucosa, skin, and cartilage — lumican is expressed in the stroma where it regulates collagen fibril diameter, interstitial fluid composition, and cell-matrix interactions. Lumican also modulates the surface availability of alpha2beta1 and alphavbeta3 integrins through direct core protein interactions, influencing cell adhesion and motility. [54] Under physiological conditions its overall effect is to maintain stromal architectural integrity, which indirectly restricts tumour cell dissemination.""",
"""In OSCC, lumican functions predominantly as a tumour suppressor. Loncar-Brzak et al. reported that stromal lumican expression is reduced in OSCC relative to normal oral connective tissue, with lowest expression in tumours exhibiting lymphovascular invasion and perineural spread. [22] Reduced lumican expression was significantly associated with shorter disease-free survival in multivariate analysis, suggesting independent prognostic value. In vitro studies demonstrate that lumican overexpression in OSCC cell lines inhibits MMP-14 (MT1-MMP)-mediated collagen I degradation, reduces cellular invasion through Matrigel, and slows in vivo tumour xenograft growth in mouse models. [23,54] The anti-invasive effect of lumican is partly attributed to its ability to promote E-cadherin-mediated cell-cell adhesion and to suppress vimentin expression, effectively reversing EMT hallmarks. [23] Conversely, lumican knockdown accelerates in vitro migration and increases MMP-14 activity, confirming its functional role in constraining OSCC invasion.""",
"""At the mechanistic level, lumican restricts OSCC invasion through two principal routes: (1) direct inhibition of MT1-MMP collagen-degrading activity, thereby reducing pericellular matrix proteolysis required for cell migration; and (2) maintenance of E-cadherin at the cell surface by preventing integrin-mediated signalling events that trigger E-cadherin endocytosis. [23,54] Lumican additionally modulates the TGF-beta axis indirectly, as its sustained stromal expression supports a matrix architecture that limits TGF-beta-driven fibroblast activation and CAF formation. Clinically, stromal lumican IHC in combination with syndecan-1 and decorin could form a panel of SLRP-based tissue markers predictive of nodal metastasis and survival outcomes in OSCC. The capacity of recombinant lumican or lumican-derived peptides to inhibit cancer cell invasion in preclinical systems supports the development of lumican-based therapeutic strategies, though OSCC-specific validation studies are still required. [23,54]"""
]
},
"5.2.4": {
"heading": "5.2.4 Fibromodulin",
"paragraphs": [
"""Fibromodulin is a KS-bearing SLRP with an LRR core protein that binds collagen types I and II at a site overlapping with the decorin-binding domain, competing with decorin during collagen fibrillogenesis. [54] It is expressed predominantly in tendons, cartilage, cornea, and oral connective tissue, where it regulates fibril diameter and the mechanical properties of collagenous matrices. Beyond matrix architecture, fibromodulin interacts with the complement system — specifically C1q and the C3 convertase — enabling it to modulate complement activation at the tissue level. [54] In oral mucosa, fibromodulin is expressed in the fibrous layer of the lamina propria and in the periodontal ligament, contributing to the mechanical resilience of the tissue and to the regulation of TGF-beta1 signalling through direct cytokine binding, analogous to decorin.""",
"""Direct OSCC-specific functional studies of fibromodulin are limited compared to decorin and lumican; however, expression data suggest relevance to oral carcinogenesis. Transcriptomic analyses of OSCC tissue datasets report altered fibromodulin expression in tumour stroma relative to normal oral mucosa, with a tendency towards downregulation in high-grade tumours consistent with general SLRP loss during malignant progression. [23,54] In other SCC subtypes — including skin and oesophageal SCC — reduced fibromodulin expression correlates with increased collagen fibril disorder, elevated TGF-beta activity, and greater invasion depth, patterns likely conserved in OSCC given the shared squamous epithelial origin. [54] Fibromodulin has additionally been reported to suppress angiogenesis by competing with VEGF for heparin-binding domains on fibronectin and by directly antagonising VEGF-A bioavailability, providing a potential anti-angiogenic mechanism relevant to OSCC tumour vascularisation. [54,55]""",
"""The mechanistic contributions of fibromodulin to OSCC are thought to mirror those of the broader SLRP family: competition with decorin for collagen-binding sites, TGF-beta1 neutralisation, and regulation of fibroblast activation. [54] Loss of fibromodulin from the tumour stroma may reduce competition with decorin for collagen binding, but if decorin is also simultaneously downregulated — as is commonly observed in OSCC — the net result is disordered fibril assembly, increased matrix compliance, and enhanced tumour cell motility. The fibromodulin-complement interaction raises the additional possibility that stromal fibromodulin loss may impair local complement-mediated tumour surveillance, contributing to immune evasion. Prospective IHC studies specifically quantifying fibromodulin in OSCC are needed to define its prognostic significance, and its inclusion in multi-SLRP biomarker panels is warranted given the functional convergence of this molecule family on key invasion and EMT pathways in squamous carcinoma. [54]"""
]
},
"5.2.5": {
"heading": "5.2.5 PRELP",
"paragraphs": [
"""Proline arginine-rich end leucine-rich repeat protein (PRELP) is a basement membrane-anchoring SLRP characterised by a highly positively charged N-terminal domain that binds heparan sulphate chains on perlecan and type II collagen-associated HS proteoglycans. [25,26] This anchoring function physically tethers the basement membrane to the underlying stroma, reinforcing epithelial-stromal integrity. PRELP is expressed in the basement membrane zones of stratified squamous epithelia, including normal oral mucosa, and its N-terminal domain additionally binds heparin and the CS chains of aggrecan, integrating it into the pericellular matrix network. In normal oral epithelium, PRELP contributes to the mechanical coupling between the epithelial basement membrane and the superficial lamina propria, opposing epithelial detachment and restraining lateral cell migration during tissue homeostasis. [25]""",
"""PRELP has emerged as a functionally significant tumour suppressor in OSCC, supported by two dedicated OSCC studies. Sun et al. demonstrated that PRELP expression is significantly downregulated in OSCC tissues compared to matched normal mucosa, and that experimental restoration of PRELP expression in OSCC cell lines suppresses EMT — increasing E-cadherin, reducing N-cadherin and vimentin — and inhibits cell migration and invasion in scratch and transwell assays. [25] A subsequent study by Sun et al. identified miR-23a-3p as a post-transcriptional regulator of PRELP: elevated miR-23a-3p in OSCC tissues directly suppresses PRELP translation, and miR-23a-3p inhibition phenocopies PRELP restoration, reducing OSCC cell invasiveness and metastatic potential in both in vitro and in vivo models. [26] Low PRELP expression in OSCC specimens correlated with advanced clinical T-stage, lymph node metastasis, and reduced overall survival, affirming its independent prognostic value. [25,26]""",
"""PRELP suppresses OSCC invasion primarily by reinforcing basement membrane integrity and antagonising the signalling pathways that drive EMT. Its physical tethering of basement membrane HS proteoglycans limits the pericellular availability of heparanase-released growth factors, reducing paracrine RTK activation. [25] Additionally, PRELP modulates the PI3K-Akt pathway in cancer cells: its downregulation disinhibits Akt phosphorylation, promoting MMP-9 secretion and invasive activity. [26] The miR-23a-3p/PRELP axis constitutes a specific and tractable therapeutic target: synthetic antagomirs against miR-23a-3p restore PRELP expression and reverse EMT in experimental systems, providing a microRNA-based therapeutic strategy. [26] Clinically, IHC for PRELP in core biopsies from OSCC patients could stratify patients at high risk of nodal spread who might benefit from intensified neck management, and combined miR-23a-3p/PRELP profiling in liquid biopsy is a prospective research priority. [25,26]"""
]
},
"5.3.1": {
"heading": "5.3.1 Versican",
"paragraphs": [
"""Versican is the largest member of the hyalectan family of CS proteoglycans (core protein 265-370 kDa depending on splice variant), and one of the most abundant ECM molecules in loose connective tissue. It exists in four splice variants (V0, V1, V2, V3) arising from alternative splicing of exons 7 and 8 encoding the CS-alpha and CS-beta attachment domains; V1 and V2 are the principal cancer-associated isoforms. [24] Versican binds hyaluronan at its N-terminal G1 domain via a link module, forming large pericellular matrices that interact with CD44, EGFR, P-selectin, and L-selectin, integrating cell-matrix adhesion with receptor-mediated signalling. [24,57] In normal oral mucosa, versican is expressed in the loose connective tissue of the lamina propria at low levels, where it contributes to tissue hydration, matrix viscoelasticity, and regulation of cell proliferation during wound healing through versikine — a bioactive N-terminal fragment generated by ADAMTS protease cleavage. [56,57]""",
"""Versican is consistently upregulated in OSCC, with stromal expression particularly pronounced at the invasion front. Xia et al. conducted IHC analysis of versican in a large OSCC tissue microarray, demonstrating that high versican expression was significantly associated with lymph node metastasis, advanced TNM stage, and shorter disease-specific survival. [24] Pukkila et al. reported that high stromal versican expression in OSCC independently predicted a worse prognosis in multivariate analysis, a finding replicated across multiple HNSCC datasets. [27] Mechanistic studies using versican knockdown in OSCC-derived cell lines showed significant reductions in cell proliferation, clonogenicity, and Matrigel invasion, consistent with a functionally important pro-tumorigenic role. [24] Versican-rich pericellular matrices have additionally been associated with resistance to CD8+ T cell-mediated cytotoxicity in solid tumours, providing a physical and molecular barrier to anti-tumour immunity. [56]""",
"""Versican promotes OSCC progression through several converging mechanisms. Its interaction with CD44 and EGFR co-activates the MAPK and PI3K-Akt pathways, sustaining proliferative and survival signalling. [57] Versican-rich matrices reduce immune cell infiltration by impeding T cell and NK cell motility and by binding immune-inhibitory ligands. [56] ADAMTS-generated versikine, paradoxically, may have anti-tumorigenic properties by activating innate immune signalling through TLR2; thus, loss of ADAMTS activity in tumours — a common finding — may simultaneously elevate intact versican and reduce immunostimulatory versikine, creating a doubly immunosuppressive environment. [56,57] Clinically, versican represents one of the most compelling therapeutic targets among OSCC proteoglycans: anti-versican antibodies, versican-binding aptamers, and ADAMTS-based fragmentation strategies are under investigation across cancer types, and their validation in OSCC is a high priority given the consistent prognostic data. [24,27,56]"""
]
},
"5.4.1": {
"heading": "5.4.1 SPOCK1",
"paragraphs": [
"""SPOCK1 (Sparc/osteonectin, cwcv- and kazal-like domains proteoglycan 1; also known as testican-1) is a secreted, modular proteoglycan carrying both HS and CS chains on a approximately 50 kDa core protein that contains an EF-hand calcium-binding domain, a thyroglobulin type-1 repeat, and a Kazal-type serine protease inhibitor domain. [58] Under physiological conditions, SPOCK1 inhibits MT-MMPs, particularly MMP-14, through its Kazal domain, serving as a natural restraint on pericellular proteolysis. It is expressed in brain, spinal cord, testes, and at lower levels in epithelial tissues, where it participates in matrix organisation and cell adhesion through interactions with perlecan, nidogen, and fibronectin. [58] The calcium-binding domain enables SPOCK1 to respond to local ionic conditions, potentially modulating its MMP-inhibitory activity in calcium-rich environments such as the pericellular space during bone invasion by OSCC.""",
"""In OSCC, SPOCK1 paradoxically adopts a pro-tumorigenic role despite its homeostatic MMP-inhibitory function. Upregulation of SPOCK1 has been reported in OSCC tissues relative to matched normal mucosa, and high SPOCK1 expression correlates with tumour depth of invasion, lymphovascular invasion, and reduced overall survival. [58] In OSCC cell line models, SPOCK1 knockdown suppresses proliferation, reduces colony formation, and impairs invasion and migration, while SPOCK1 overexpression produces the converse phenotype. [58] Li et al. demonstrated in pancreatic cancer that SPOCK1 activates the SDF-1/CXCR4 axis to promote EMT and invasion — a mechanism potentially operative in OSCC given the shared mesenchymal transition biology. [59] Zhang et al. showed in hepatocellular carcinoma that SPOCK1 independently predicts recurrence-free survival, and pathway enrichment analysis identified Wnt-beta-catenin and PI3K-Akt as the principal downstream effectors. [58]""",
"""The oncogenic switch of SPOCK1 in OSCC likely reflects a functional context shift: in tumours characterised by high MMP activity, SPOCK1-mediated MMP-14 inhibition may redirect proteolytic activity towards HS-releasing heparanase and other non-MMP matrix-remodelling enzymes, paradoxically facilitating a more invasive microenvironment. Alternatively, SPOCK1 may promote invasion through non-proteolytic mechanisms, including activation of Wnt-beta-catenin signalling via its CS chains and CXCR4-mediated chemotaxis towards stromal SDF-1 gradients. [58,59] The dual MMP-inhibitory and pro-invasive activities of SPOCK1 make it a challenging therapeutic target: blanket inhibition risks disrupting physiological MMP regulation, while targeting the SPOCK1-CXCR4 interaction specifically is more tractable. Clinically, SPOCK1 IHC in pre-treatment OSCC biopsies has potential as a prognostic biomarker of deep invasion, and its utility in conjunction with versican and syndecan-1 in a multi-molecule prognostic panel warrants prospective validation. [58,59]"""
]
},
"5.4.2": {
"heading": "5.4.2 CSPG4 (NG2)",
"paragraphs": [
"""Chondroitin sulphate proteoglycan 4 (CSPG4), also designated NG2 (neuron-glial antigen 2), is a large (300 kDa) type I transmembrane CS proteoglycan originally identified on oligodendrocyte progenitor cells and pericytes. [60] Its extracellular domain carries a single CS chain and contains multiple functional modules — including a domain that binds collagen V/VI, laminin, fibronectin, and platelet-derived growth factor (PDGF) — while its cytoplasmic C-terminal domain interacts with the PDZ scaffold protein MUPP1 and activates integrin-linked kinase (ILK). [60] In normal tissues, CSPG4 expression is restricted to pericytes of the microvasculature, immature oligodendrocyte precursors, and activated melanocytes; it is essentially absent from normal oral epithelium. This restricted normal-tissue expression and its prominent re-expression on tumour cells and tumour-associated pericytes make CSPG4 an attractive selective target for cancer therapy. [60]""",
"""CSPG4 is aberrantly expressed in OSCC and a spectrum of related squamous carcinomas. Chen et al. identified CSPG4 as a marker for aggressive SCC by IHC and flow cytometry analysis, demonstrating high CSPG4 surface expression on tumour cells in OSCC specimens and correlating expression with tumour grade, local invasion, and a cancer stem cell-like phenotype characterised by high CD44 and low E-cadherin. [32] Campoli et al. comprehensively reviewed CSPG4 biology across solid tumours and confirmed that CSPG4-positive tumour cells display enhanced activation of the FAK-Src, MEK-ERK, and PI3K-Akt signalling cascades through CSPG4-integrin and CSPG4-PDGFR co-receptor activities, driving cell proliferation, survival, and migration. [60] The presence of CSPG4 on tumour-associated pericytes further promotes angiogenesis by sustaining PDGF-BB signalling essential for pericyte recruitment and microvessel stabilisation, creating a pro-vascular environment supportive of tumour expansion. [60]""",
"""CSPG4 promotes OSCC progression through integrin co-receptor activity (particularly alpha3beta1 and alpha4beta1), collagen matrix adhesion, PDGF-mediated pericyte signalling, and activation of Rho GTPases that drive cytoskeletal reorganisation and lamellipodia formation. [60] Importantly, CSPG4's restricted normal-tissue expression profile makes it an ideal antibody target: anti-CSPG4 monoclonal antibodies conjugated to ricin toxin or to immunotoxins have demonstrated selective cytotoxicity against CSPG4-positive tumour cells in preclinical melanoma and HNSCC models, with minimal on-target off-tumour toxicity. [60] CAR-T cell constructs targeting CSPG4 are in early-phase development for melanoma and have demonstrated efficacy in co-culture models with OSCC cell lines, providing a strong rationale for clinical translation. [60] The combination of CSPG4's diagnostic utility — as an IHC/flow cytometry marker stratifying high-risk OSCC — and its actionability as a therapeutic target positions it as one of the most immediately translatable proteoglycans in OSCC management. [32,60]"""
]
},
}

# ── Mapping from heading text to SEC5 key ──────────────────────────────────
HEADING_MAP = {
    "5.1.1 Perlecan": "5.1.1",
    "5.1.2 Agrin": "5.1.2",
    "5.1.3 Syndecan-1": "5.1.3",
    "5.1.4 Glypicans (GPC1, GPC3, GPC5)": "5.1.4",
    "5.2.1 Decorin": "5.2.1",
    "5.2.2 Biglycan": "5.2.2",
    "5.2.3 Lumican": "5.2.3",
    "5.2.4 Fibromodulin": "5.2.4",
    "5.2.5 PRELP": "5.2.5",
    "5.3.1 Versican": "5.3.1",
    "5.4.1 SPOCK1": "5.4.1",
    "5.4.2 CSPG4 (NG2)": "5.4.2",
}

# ── Load source docx ───────────────────────────────────────────────────────
src = '/tmp/workspace/attachments/d3da3433-5073-4e88-b3fb-a7814739edbb/Proteoglycans_OSCC_v3_expanded (1).docx'
doc = Document(src)

from docx.oxml.ns import qn
from docx.oxml import OxmlElement
from lxml import etree

def add_para_after(doc_obj, ref_para, text, style_name='Normal'):
    """Insert a new paragraph with given text and style immediately after ref_para."""
    new_para = OxmlElement('w:p')
    ref_para._p.addnext(new_para)
    # Now address the newly-inserted paragraph via doc
    # We'll use python-docx's run-based approach on the element directly
    new_p = ref_para._p.getnext()
    # set style
    pPr = OxmlElement('w:pPr')
    pStyle = OxmlElement('w:pStyle')
    # find style id for style_name
    style_id = style_name.replace(' ', '')
    pStyle.set(qn('w:val'), style_id)
    pPr.append(pStyle)
    new_p.append(pPr)
    # add run with text
    run_el = OxmlElement('w:r')
    t_el = OxmlElement('w:t')
    t_el.text = text
    t_el.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve')
    run_el.append(t_el)
    new_p.append(run_el)
    return new_p

# Build new document paragraph list:
# Strategy: collect all paragraphs, replace content of sec5 normal paras,
# and insert new ones where needed.

# We'll rebuild the doc by collecting elements in order,
# replacing old sec5 subsection content with new expanded content.

paras = list(doc.paragraphs)

# Find all Heading 3 paragraphs that match our heading map
# For each: collect immediately following Normal paragraphs (old content)
# Replace first para text with P1, add P2 and P3 after.

# We need to work at the XML level to insert paragraphs properly.
# Collect para indices for each molecule heading
molecule_ranges = {}  # heading_text -> (heading_para_index, [body_para_indices])

i = 0
while i < len(paras):
    p = paras[i]
    h_text = p.text.strip()
    if h_text in HEADING_MAP and p.style.name.startswith('Heading'):
        # collect following Normal paras until next heading
        body_indices = []
        j = i + 1
        while j < len(paras) and not paras[j].style.name.startswith('Heading'):
            if paras[j].text.strip():
                body_indices.append(j)
            j += 1
        molecule_ranges[h_text] = (i, body_indices)
    i += 1

print("Molecules found in document:")
for h, (hi, bi) in molecule_ranges.items():
    print(f"  {h}: heading at {hi}, body paras at {bi}")

# Now for each molecule, do the replacement:
# 1. Set text of first body para = P1 of expanded content
# 2. Set text of subsequent existing body paras (if any) = P2, P3
# 3. If not enough existing paras, insert new ones

from docx.oxml.ns import qn
from lxml import etree

def set_para_text(para, text):
    """Replace all runs in para with a single run containing text."""
    p = para._p
    # Remove all existing runs and hyperlinks
    for child in list(p):
        tag = child.tag.split('}')[-1] if '}' in child.tag else child.tag
        if tag in ('r', 'hyperlink', 'ins', 'del'):
            p.remove(child)
    # Add new run
    r = OxmlElement('w:r')
    t = OxmlElement('w:t')
    t.text = text
    t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve')
    r.append(t)
    p.append(r)

def insert_para_after_element(el, text, style_id='Normal'):
    """Insert a new <w:p> element after el with given text."""
    new_p = OxmlElement('w:p')
    # pPr with style
    pPr = OxmlElement('w:pPr')
    pStyle = OxmlElement('w:pStyle')
    pStyle.set(qn('w:val'), style_id)
    pPr.append(pStyle)
    new_p.append(pPr)
    # run
    r = OxmlElement('w:r')
    t = OxmlElement('w:t')
    t.text = text
    t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve')
    r.append(t)
    new_p.append(r)
    el.addnext(new_p)
    return new_p

for h_text, (hi, body_indices) in molecule_ranges.items():
    key = HEADING_MAP[h_text]
    new_paras_text = SEC5[key]['paragraphs']  # list of 3 strings
    
    heading_para = paras[hi]
    
    if len(body_indices) == 0:
        # No existing body paras - insert all 3 after heading
        prev_el = heading_para._p
        for txt in new_paras_text:
            new_el = insert_para_after_element(prev_el, txt)
            prev_el = new_el
    elif len(body_indices) == 1:
        # 1 existing para -> replace it with P1, insert P2 and P3 after
        set_para_text(paras[body_indices[0]], new_paras_text[0])
        prev_el = paras[body_indices[0]]._p
        for txt in new_paras_text[1:]:
            new_el = insert_para_after_element(prev_el, txt)
            prev_el = new_el
    elif len(body_indices) == 2:
        # 2 existing -> replace P1, P2; insert P3 after second
        set_para_text(paras[body_indices[0]], new_paras_text[0])
        set_para_text(paras[body_indices[1]], new_paras_text[1])
        prev_el = paras[body_indices[1]]._p
        new_el = insert_para_after_element(prev_el, new_paras_text[2])
    else:
        # 3+ existing -> replace first 3
        set_para_text(paras[body_indices[0]], new_paras_text[0])
        set_para_text(paras[body_indices[1]], new_paras_text[1])
        set_para_text(paras[body_indices[2]], new_paras_text[2])
        # remove any extra
        for extra_idx in body_indices[3:]:
            p_el = paras[extra_idx]._p
            p_el.getparent().remove(p_el)

    print(f"  Expanded: {h_text}")

# ── Save ───────────────────────────────────────────────────────────────────
out = '/tmp/workspace/revised-manuscript/Proteoglycans_OSCC_v4_fullsec5.docx'
doc.save(out)
print(f"\nSaved: {out}")

# ── Word count check ───────────────────────────────────────────────────────
doc2 = Document(out)
in_refs = False
body_words = 0
sec5_words = 0
in_sec5 = False
for p in doc2.paragraphs:
    if 'REFERENCES' in p.text.upper() and p.style.name.startswith('Heading'):
        in_refs = True
    if '5. INDIVIDUAL' in p.text and p.style.name.startswith('Heading'):
        in_sec5 = True
    if in_sec5 and p.style.name.startswith('Heading') and p.text.strip().startswith('6.'):
        in_sec5 = False
    if not in_refs and p.text.strip():
        body_words += len(p.text.split())
    if in_sec5 and p.text.strip():
        sec5_words += len(p.text.split())
print(f"Body word count: {body_words}")
print(f"Section 5 word count: {sec5_words}")

"""
Figure 1: Proteoglycan localisation and signalling in the OSCC tumour microenvironment.

Layout (left to right, 4 vertical zones):
  Zone A – Tumour cell (centre-left)
  Zone B – Basement membrane strip
  Zone C – Stroma / ECM
  Zone D – Signalling outcome boxes (right column)

The figure shows:
  - OSCC tumour cell with cell-surface PGs (SDC1, GPC1/3/5, CSPG4)
  - Basement membrane with BM PGs (Perlecan, Agrin)
  - Stromal ECM with SLRPs (Decorin, Biglycan, Lumican, Fibromodulin, PRELP)
    and large ECM PGs (Versican) and secreted PGs (SPOCK1)
  - Heparanase (HPSE1) acting on BM and cell-surface HS chains
  - Arrows to signalling outcomes:
      RTK activation (EGFR, FGFR, MET) -> Proliferation / Survival
      EMT (TGF-β / Smad) -> Invasion / Metastasis
      Immune evasion (Versican, Biglycan) -> Immune exclusion
      Anti-tumour (Decorin, Lumican, PRELP) -> Tumour suppression
"""

import matplotlib
matplotlib.use('Agg')
import matplotlib.pyplot as plt
import matplotlib.patches as mpatches
from matplotlib.patches import FancyArrowPatch, FancyBboxPatch, Arc, Circle, Ellipse
from matplotlib.patheffects import withStroke
import matplotlib.patheffects as pe
import numpy as np

# ── Figure setup ────────────────────────────────────────────────────────────
fig, ax = plt.subplots(figsize=(18, 11))
ax.set_xlim(0, 18)
ax.set_ylim(0, 11)
ax.axis('off')
fig.patch.set_facecolor('white')

# ── Colour palette ───────────────────────────────────────────────────────────
C = {
    'tumour_bg':    '#FFF3E0',   # light amber – tumour cell body
    'tumour_border':'#E65100',   # dark orange
    'nucleus_bg':   '#FFCCBC',
    'nucleus_border':'#BF360C',
    'bm_bg':        '#E8F5E9',   # light green – basement membrane
    'bm_border':    '#2E7D32',
    'stroma_bg':    '#E3F2FD',   # light blue – stroma
    'stroma_border':'#1565C0',
    'slrp_sup':     '#1B5E20',   # dark green – tumour suppressor SLRPs
    'slrp_pro':     '#B71C1C',   # dark red – pro-tumour
    'large_pg':     '#4A148C',   # purple – versican / large ECM
    'spock':        '#E65100',   # orange – SPOCK1
    'hpse':         '#880E4F',   # magenta – heparanase
    'cell_surf':    '#0D47A1',   # dark blue – cell-surface PGs
    'cspg4':        '#006064',   # teal – CSPG4
    'outcome_pro':  '#B71C1C',
    'outcome_sup':  '#1B5E20',
    'outcome_imm':  '#4A148C',
    'arrow_pro':    '#E53935',
    'arrow_sup':    '#43A047',
    'arrow_hpse':   '#AD1457',
    'title_bg':     '#1A237E',
    'white':        '#FFFFFF',
    'light_grey':   '#F5F5F5',
    'text_dark':    '#212121',
}

def txt(x, y, s, fs=8, color='#212121', ha='center', va='center',
        bold=False, wrap=False, zorder=5):
    w = 'bold' if bold else 'normal'
    ax.text(x, y, s, fontsize=fs, color=color, ha=ha, va=va,
            fontweight=w, zorder=zorder,
            path_effects=[pe.withStroke(linewidth=0, foreground='white')])

def box(x, y, w, h, fc, ec, lw=1.2, alpha=1.0, zorder=2, radius=0.15):
    rect = FancyBboxPatch((x, y), w, h,
                          boxstyle=f"round,pad=0,rounding_size={radius}",
                          facecolor=fc, edgecolor=ec, linewidth=lw,
                          alpha=alpha, zorder=zorder)
    ax.add_patch(rect)

def pill(x, y, w, h, fc, ec, lw=1.0, zorder=4):
    """Small rounded pill label."""
    rect = FancyBboxPatch((x - w/2, y - h/2), w, h,
                          boxstyle="round,pad=0,rounding_size=0.12",
                          facecolor=fc, edgecolor=ec, linewidth=lw, zorder=zorder)
    ax.add_patch(rect)

def arrow(x1, y1, x2, y2, color='#333333', lw=1.5,
          style='->', head=10, zorder=4, ls='-'):
    ax.annotate('', xy=(x2, y2), xytext=(x1, y1),
                arrowprops=dict(arrowstyle=f'->', color=color,
                                lw=lw, connectionstyle='arc3,rad=0.0',
                                mutation_scale=head),
                zorder=zorder)

def dashed_arrow(x1, y1, x2, y2, color, lw=1.2, head=9, zorder=4):
    ax.annotate('', xy=(x2, y2), xytext=(x1, y1),
                arrowprops=dict(arrowstyle='->', color=color,
                                lw=lw, connectionstyle='arc3,rad=0.0',
                                linestyle='dashed', mutation_scale=head),
                zorder=zorder)

# ═══════════════════════════════════════════════════════════════════════════
# TITLE BAR
# ═══════════════════════════════════════════════════════════════════════════
box(0.15, 10.2, 17.7, 0.62, C['title_bg'], C['title_bg'], lw=0, zorder=3)
txt(9, 10.52,
    'Figure 1.  Proteoglycan Localisation and Signalling in the OSCC Tumour Microenvironment',
    fs=11, color='white', bold=True)

# ═══════════════════════════════════════════════════════════════════════════
# ZONE BACKGROUNDS
# ═══════════════════════════════════════════════════════════════════════════
# Zone A – Tumour cell area
box(0.2, 0.3, 5.1, 9.7, C['tumour_bg'], C['tumour_border'], lw=1.5, alpha=0.6, radius=0.3)
txt(2.75, 9.8, 'TUMOUR CELL', fs=9, color=C['tumour_border'], bold=True)

# Zone B – Basement membrane
box(5.4, 0.3, 1.5, 9.7, C['bm_bg'], C['bm_border'], lw=1.5, alpha=0.65, radius=0.2)
txt(6.15, 9.8, 'BASEMENT\nMEMBRANE', fs=8, color=C['bm_border'], bold=True)

# Zone C – Stroma
box(7.0, 0.3, 5.9, 9.7, C['stroma_bg'], C['stroma_border'], lw=1.5, alpha=0.5, radius=0.3)
txt(9.95, 9.8, 'STROMA / ECM', fs=9, color=C['stroma_border'], bold=True)

# Zone D – Outcomes
box(13.1, 0.3, 4.8, 9.7, C['light_grey'], '#9E9E9E', lw=1.2, alpha=0.7, radius=0.3)
txt(15.5, 9.8, 'SIGNALLING OUTCOMES', fs=9, color='#424242', bold=True)

# ═══════════════════════════════════════════════════════════════════════════
# TUMOUR CELL BODY (large ellipse)
# ═══════════════════════════════════════════════════════════════════════════
cell_cx, cell_cy = 2.7, 5.0
cell_ell = Ellipse((cell_cx, cell_cy), width=4.0, height=7.5,
                   facecolor='#FFE0B2', edgecolor=C['tumour_border'],
                   linewidth=2.0, zorder=3)
ax.add_patch(cell_ell)

# Nucleus
nuc = Ellipse((cell_cx, cell_cy), width=1.8, height=2.2,
              facecolor=C['nucleus_bg'], edgecolor=C['nucleus_border'],
              linewidth=1.5, zorder=4)
ax.add_patch(nuc)
txt(cell_cx, cell_cy, 'Nucleus', fs=7.5, color=C['nucleus_border'], bold=True)

# ── Label inside cell: signalling cascades triggered ────────────────────
txt(cell_cx, 2.2, 'MAPK/ERK', fs=7, color='#5D4037', bold=False)
txt(cell_cx, 1.8, 'PI3K–Akt', fs=7, color='#5D4037')
txt(cell_cx, 1.4, 'Wnt–β-catenin', fs=7, color='#5D4037')
txt(cell_cx, 1.0, 'NF-κB', fs=7, color='#5D4037')

# Bracket label for cascades
box(1.3, 0.75, 2.8, 1.75, '#FFF8E1', '#FFB300', lw=1, radius=0.1, zorder=3)
txt(2.7, 1.62, 'Downstream', fs=6.5, color='#5D4037', bold=True)
txt(2.7, 1.45, 'signalling cascades', fs=6.5, color='#5D4037')

# ═══════════════════════════════════════════════════════════════════════════
# CELL-SURFACE PROTEOGLYCANS (on tumour cell membrane, right side of ellipse)
# ═══════════════════════════════════════════════════════════════════════════
# Membrane right edge at x ≈ 4.7 (cell_cx + 2.0)
mem_x = 4.55

# SDC1 spike (transmembrane rod)
for i, (ypos, label, fc) in enumerate([
    (8.1, 'SDC1\n(CD138)', '#1565C0'),
    (7.0, 'GPC1/3/5', '#0288D1'),
    (5.9, 'CSPG4\n(NG2)',  '#00695C'),
]):
    # rod
    ax.plot([mem_x - 0.55, mem_x + 0.05], [ypos, ypos],
            color=fc, lw=2.5, zorder=5)
    # HS chain wiggle (sinusoid)
    xs = np.linspace(mem_x - 0.55, mem_x - 0.05, 40)
    ys = ypos + 0.18 * np.sin(np.linspace(0, 4*np.pi, 40))
    ax.plot(xs, ys + 0.28, color='#43A047', lw=1.2, zorder=5)
    # pill label
    pill(mem_x - 0.25, ypos, 0.75, 0.38, fc, fc, lw=0, zorder=6)
    txt(mem_x - 0.25, ypos, label, fs=6.2, color='white', bold=True)

# ═══════════════════════════════════════════════════════════════════════════
# SHED SDC1 ECTODOMAIN (diffusing into stroma)
# ═══════════════════════════════════════════════════════════════════════════
# small SDC1 fragment floating in stroma zone
pill(8.2, 6.5, 0.95, 0.38, '#1565C0', '#1565C0', lw=0, zorder=6)
txt(8.2, 6.5, 'Shed SDC1', fs=6.5, color='white', bold=True)
txt(8.2, 6.1, '(ectodomain)', fs=6, color='#1565C0')
# dashed arrow from cell surface to shed fragment
dashed_arrow(4.6, 8.1, 7.7, 6.55, C['arrow_pro'], lw=1.1, head=8)
txt(6.1, 7.6, 'MMP/ADAM\nshedding', fs=6, color=C['hpse'])

# ═══════════════════════════════════════════════════════════════════════════
# BASEMENT MEMBRANE ZONE – Perlecan & Agrin
# ═══════════════════════════════════════════════════════════════════════════
bm_x = 5.9
# Perlecan - multimodular structure (series of ovals)
for yi, col in [(7.8, '#2E7D32'), (6.8, '#2E7D32')]:
    for xi_off in [-0.2, 0.0, 0.2]:
        circ = Ellipse((bm_x + xi_off, yi), 0.28, 0.32,
                       facecolor='#A5D6A7', edgecolor=col, lw=1.0, zorder=5)
        ax.add_patch(circ)
    # HS chain
    xs2 = np.linspace(bm_x - 0.3, bm_x + 0.3, 30)
    ys2 = yi + 0.32 + 0.12 * np.sin(np.linspace(0, 3*np.pi, 30))
    ax.plot(xs2, ys2, color='#43A047', lw=1.4, zorder=6)

txt(bm_x, 8.35, 'Perlecan', fs=6.8, color=C['bm_border'], bold=True)
txt(bm_x, 7.35, 'Agrin', fs=6.8, color=C['bm_border'], bold=True)

# Endorepellin fragment label
pill(bm_x, 4.8, 1.1, 0.36, '#81C784', C['bm_border'], lw=1, zorder=5)
txt(bm_x, 4.8, 'Endorepellin', fs=6.2, color=C['bm_border'], bold=True)
txt(bm_x, 4.45, '(anti-angiogenic)', fs=5.8, color='#2E7D32')
arrow(bm_x, 7.5, bm_x, 5.0, color=C['slrp_sup'], lw=1.2, head=8)
txt(bm_x + 0.5, 6.2, 'Cleavage\n→ endorepellin', fs=5.8, color='#2E7D32', ha='left')

# ═══════════════════════════════════════════════════════════════════════════
# HEPARANASE (HPSE1) – enzyme acting on BM and cell surface
# ═══════════════════════════════════════════════════════════════════════════
pill(6.3, 5.85, 1.1, 0.38, '#FCE4EC', C['hpse'], lw=1.5, zorder=7)
txt(6.3, 5.85, 'HPSE1', fs=7.5, color=C['hpse'], bold=True)
# scissors symbol equivalent – two short lines
ax.plot([5.85, 6.25], [5.72, 5.60], color=C['hpse'], lw=1.4, zorder=8)
ax.plot([5.85, 6.25], [5.60, 5.72], color=C['hpse'], lw=1.4, zorder=8)

# HPSE cleaves HS on perlecan -> releases GFs
dashed_arrow(6.3, 6.05, 6.1, 7.3, C['hpse'], lw=1.3)
txt(5.6, 6.8, 'HS\ncleavage', fs=5.8, color=C['hpse'], ha='center')

# Released GFs box
pill(8.5, 5.2, 1.3, 0.38, '#FCE4EC', C['hpse'], lw=1, zorder=5)
txt(8.5, 5.2, 'FGF-2 / VEGF / HGF', fs=6, color=C['hpse'], bold=True)
txt(8.5, 4.82, 'Released GFs', fs=5.8, color=C['hpse'])
dashed_arrow(6.8, 5.85, 7.9, 5.22, C['hpse'], lw=1.2)

# ═══════════════════════════════════════════════════════════════════════════
# STROMAL SLRPs – tumour suppressive (left stroma column)
# ═══════════════════════════════════════════════════════════════════════════
# Draw stylised bowtie shapes for SLRPs
slrp_sup_x = 8.5
for yi, name in [(8.8, 'Decorin'), (8.0, 'Lumican'), (7.2, 'PRELP'),
                 (6.4, 'Fibromodulin')]:
    pill(slrp_sup_x, yi, 1.2, 0.36, '#E8F5E9', C['slrp_sup'], lw=1.2, zorder=5)
    txt(slrp_sup_x, yi, name, fs=7, color=C['slrp_sup'], bold=True)

txt(slrp_sup_x, 9.3, 'Tumour-Suppressive SLRPs', fs=7.5, color=C['slrp_sup'],
    bold=True)

# Pro-tumorigenic SLRPs (biglycan) + Versican right stroma column
slrp_pro_x = 10.5
pill(slrp_pro_x, 8.8, 1.1, 0.36, '#FFEBEE', C['slrp_pro'], lw=1.2, zorder=5)
txt(slrp_pro_x, 8.8, 'Biglycan', fs=7, color=C['slrp_pro'], bold=True)

pill(slrp_pro_x, 7.8, 1.1, 0.38, '#F3E5F5', C['large_pg'], lw=1.2, zorder=5)
txt(slrp_pro_x, 7.8, 'Versican', fs=7, color=C['large_pg'], bold=True)

pill(slrp_pro_x, 6.8, 1.0, 0.36, '#FFF3E0', C['spock'], lw=1.2, zorder=5)
txt(slrp_pro_x, 6.8, 'SPOCK1', fs=7, color=C['spock'], bold=True)

txt(slrp_pro_x, 9.3, 'Pro-Tumorigenic PGs', fs=7.5, color=C['slrp_pro'],
    bold=True)

# Collagen fibril motif in stroma (background texture)
for xi in [7.4, 9.0, 10.0, 11.0, 12.3]:
    for yi in [1.0, 1.8, 2.6, 3.4]:
        ax.plot([xi, xi + 0.6], [yi, yi],
                color='#BBDEFB', lw=0.8, zorder=1, alpha=0.7)

# Collagen label
txt(9.5, 2.2, 'Collagen fibril network', fs=7, color='#90CAF9', ha='center')

# ═══════════════════════════════════════════════════════════════════════════
# SIGNALLING PATHWAY ARROWS – stroma PGs → outcomes
# ═══════════════════════════════════════════════════════════════════════════

# 1. Suppressive SLRPs → Tumour suppression outcome
arrow(9.15, 8.1, 13.15, 8.3, color=C['arrow_sup'], lw=1.8, head=10)
txt(11.1, 8.55, 'TGF-β neutralisation\nEGFR degradation\nMMP-14 inhibition',
    fs=6.2, color=C['slrp_sup'], ha='center')

# 2. Pro-tumorigenic PGs → Invasion/Metastasis
arrow(11.1, 7.8, 13.15, 6.95, color=C['arrow_pro'], lw=1.8, head=10)
txt(12.1, 7.55, 'CD44/EGFR\nco-activation', fs=6.2, color=C['slrp_pro'], ha='center')

# 3. Biglycan → Immune evasion
arrow(11.1, 8.8, 13.15, 5.55, color='#7B1FA2', lw=1.6, head=10)
txt(12.4, 7.1, 'TLR2/4 → NF-κB', fs=6.2, color='#7B1FA2', ha='center')

# 4. Released GFs → RTK activation
arrow(9.8, 5.05, 13.15, 4.2, color=C['hpse'], lw=1.6, head=10)
txt(11.5, 4.8, 'RTK (FGFR/EGFR)\nactivation', fs=6.2, color=C['hpse'], ha='center')

# 5. CSPG4 / SDC1 → Proliferation/Survival
arrow(4.8, 6.0, 13.15, 2.9, color=C['cell_surf'], lw=1.5, head=10)
txt(8.8, 4.0, 'Integrin–FAK–Src\nPI3K–Akt', fs=6.2, color=C['cell_surf'], ha='center')

# ═══════════════════════════════════════════════════════════════════════════
# OUTCOME BOXES (Zone D)
# ═══════════════════════════════════════════════════════════════════════════
outcomes = [
    # (y_centre, label, sublabel, fc, ec)
    (8.3,  'TUMOUR SUPPRESSION',     'Apoptosis ↑  Proliferation ↓\nAngiogenesis ↓  Invasion ↓',
           '#E8F5E9', C['slrp_sup']),
    (6.85, 'EMT & INVASION',         'E-cadherin ↓  Vimentin ↑\nMMP secretion ↑  Migration ↑',
           '#FFEBEE', C['slrp_pro']),
    (5.45, 'IMMUNE EVASION',         'IL-6/IL-8 ↑  T-cell exclusion\nImmuno-suppressive TME',
           '#F3E5F5', '#7B1FA2'),
    (4.05, 'ANGIOGENESIS',           'VEGF / FGF-2 release\nEndothelial activation ↑',
           '#FCE4EC', C['hpse']),
    (2.75, 'PROLIFERATION\n& SURVIVAL', 'MAPK/ERK ↑  PI3K–Akt ↑\nAnti-apoptotic signals ↑',
           '#E3F2FD', C['cell_surf']),
]

for (yc, label, sub, fc, ec) in outcomes:
    box(13.25, yc - 0.72, 4.45, 1.44, fc, ec, lw=1.8, zorder=5, radius=0.2)
    txt(15.48, yc + 0.28, label, fs=7.5, color=ec, bold=True)
    txt(15.48, yc - 0.18, sub, fs=6.2, color='#424242')

# ═══════════════════════════════════════════════════════════════════════════
# LEGEND STRIP (bottom)
# ═══════════════════════════════════════════════════════════════════════════
legend_y = 0.62
box(0.2, 0.15, 17.6, 0.9, '#F5F5F5', '#BDBDBD', lw=0.8, radius=0.1)
txt(1.0, legend_y, 'Legend:', fs=7.5, color='#424242', bold=True, ha='left')

legend_items = [
    (2.5,  '#A5D6A7', '#2E7D32', 'BM proteoglycans\n(Perlecan, Agrin)'),
    (5.0,  '#E8F5E9', '#1B5E20', 'Tumour-suppressive SLRPs\n(Decorin, Lumican, PRELP, Fibro.)'),
    (7.8,  '#FFEBEE', '#B71C1C', 'Pro-tumorigenic PGs\n(Versican, Biglycan, SPOCK1)'),
    (10.4, '#E3F2FD', '#0D47A1', 'Cell-surface PGs\n(SDC1, GPC1/3/5, CSPG4)'),
    (13.2, '#FCE4EC', '#880E4F', 'HPSE1 (Heparanase)\n& released growth factors'),
]
for (lx, fc, ec, label) in legend_items:
    rect = FancyBboxPatch((lx - 0.22, legend_y - 0.24), 0.44, 0.48,
                          boxstyle="round,pad=0,rounding_size=0.05",
                          facecolor=fc, edgecolor=ec, lw=1.0, zorder=6)
    ax.add_patch(rect)
    txt(lx + 0.55, legend_y, label, fs=6, color='#424242', ha='left')

# ═══════════════════════════════════════════════════════════════════════════
# KEY PATHWAY LABELS ON ARROWS (inside figure)
# ═══════════════════════════════════════════════════════════════════════════
# Note label for PRELP miR-23a-3p
txt(9.0, 3.6, 'miR-23a-3p ↑\n→ PRELP ↓', fs=5.8, color='#1B5E20', ha='center')
# Note label for SDC1 shedding
txt(5.8, 9.3, 'SDC1 loss\n→ EMT', fs=5.8, color=C['tumour_border'], ha='center')

# ═══════════════════════════════════════════════════════════════════════════
# VERSICAN immunosuppression note
# ═══════════════════════════════════════════════════════════════════════════
txt(10.5, 7.25, 'CD8+ T-cell\nexclusion', fs=5.8, color=C['large_pg'], ha='center')

# ═══════════════════════════════════════════════════════════════════════════
# SAVE
# ═══════════════════════════════════════════════════════════════════════════
out_png = '/tmp/workspace/revised-manuscript/Figure1_PG_OSCC_TME.png'
out_pdf = '/tmp/workspace/revised-manuscript/Figure1_PG_OSCC_TME.pdf'
plt.tight_layout(pad=0.3)
fig.savefig(out_png, dpi=300, bbox_inches='tight', facecolor='white')
fig.savefig(out_pdf, bbox_inches='tight', facecolor='white')
plt.close()
print(f"Saved PNG: {out_png}")
print(f"Saved PDF: {out_pdf}")
import os
print(f"PNG size: {os.path.getsize(out_png)//1024} KB")

"""
Build v6: 
1. Replace Section 7.2 paragraphs (indices 107 and 108) with 3 expanded paragraphs
2. Add Table 3 (therapeutic targets, 10 data rows) immediately after Section 7.2
3. Add a Table 3 caption line after the table
"""

from docx import Document
from docx.shared import Pt, RGBColor, Inches
from docx.oxml import OxmlElement
from docx.oxml.ns import qn
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT, WD_ALIGN_VERTICAL
from docx.shared import Cm

# ── New Section 7.2 content (3 paragraphs ~350 words) ──────────────────────

P7_2 = [

# Paragraph 1 – Recombinant biologics and ECM-targeted agents
"""The biological roles of proteoglycans in OSCC present multiple potential points of 
therapeutic intervention, falling into three broad categories: recombinant proteoglycan 
biologics, proteoglycan-targeted antibody therapies, and small-molecule inhibitors of 
proteoglycan-modifying enzymes. Recombinant decorin core protein has demonstrated 
anti-tumour, anti-angiogenic, and anti-fibrotic activity in preclinical solid tumour models 
by simultaneously antagonising TGF-beta1 (via direct cytokine sequestration), EGFR 
(via receptor ubiquitination and degradation), and VEGFR2. [53,62] Endorepellin, 
the anti-angiogenic C-terminal fragment of perlecan, suppresses tumour growth in xenograft 
models by engaging alpha2beta1 integrin and VEGFR2, reducing endothelial cell migration and 
tube formation. [61] Although neither agent has yet entered a registered clinical trial in 
OSCC specifically, both are mechanistically active across multiple solid tumour types and 
represent high-priority candidates for Phase I evaluation in recurrent or metastatic OSCC, 
particularly given the established downregulation of endogenous decorin and fragmentation 
of perlecan in invasive OSCC tissue. [21,61,62]""".replace('\n', ' ').strip(),

# Paragraph 2 – Antibody-based and cell-based therapies
"""Syndecan-1 (CD138) and CSPG4 are the most clinically advanced proteoglycan targets. 
Indatuximab ravtansine (BT-062), an anti-CD138 antibody conjugated to the microtubule 
inhibitor DM4, has been evaluated in Phase I/II trials in relapsed/refractory multiple 
myeloma (NCT01638936), demonstrating acceptable tolerability and objective responses in 
CD138-positive disease. [48] Given the consistent finding of aberrant SDC1 expression in 
OSCC — loss of membranous staining, elevated serum shedding, and EMT-associated 
redistribution — the scientific rationale for testing CD138-directed ADCs in SDC1-high 
OSCC subgroups is compelling. For CSPG4, anti-CSPG4 monoclonal antibodies linked to 
immunotoxins (PE38) or cytotoxic payloads have shown selective in vitro cytotoxicity 
against CSPG4-positive HNSCC cell lines, and a CSPG4-targeted CAR-T cell approach 
demonstrated efficacy in preclinical melanoma models. [32,60] Glypican-3-targeted 
immunotherapy — most advanced in hepatocellular carcinoma with agents such as GC33 
(codrituzumab, NCT01507168) and GPC3-directed CAR-T constructs — provides a direct 
translational template for GPC3-overexpressing OSCC, supported by the IHC evidence of 
GPC3 upregulation in oral carcinoma. [18,49,50]""".replace('\n', ' ').strip(),

# Paragraph 3 – Small-molecule enzyme inhibitors (heparanase, ADAM, MMP)
"""Small-molecule inhibitors targeting proteoglycan-modifying enzymes offer a 
pan-proteoglycan approach to disrupting multiple HS-dependent signalling axes 
simultaneously. Roneparstat (SST0001), a modified heparin that competitively inhibits 
heparanase-1, reduces HS catabolism, limits growth factor liberation from ECM, and has 
been evaluated in a Phase I/II clinical trial in relapsed multiple myeloma 
(NCT01764880), demonstrating disease stabilisation in heavily pre-treated patients. [45] 
Pixatimod (PG545), a heparan sulphate mimetic with dual heparanase-inhibitory and 
immune-stimulatory activity, has completed Phase I evaluation in advanced solid tumours 
(NCT02042781), showing evidence of NK cell activation and tumour control. [45] Both 
compounds warrant evaluation in OSCC cohorts, given the evidence that HPSE1 upregulation 
independently predicts reduced survival in oral cancer. [42] Selective ADAM10/17 
inhibitors (e.g., INCB7839, currently in trials for HER2-positive breast cancer, 
NCT02022202) could interrupt syndecan-1 ectodomain shedding and simultaneously reduce 
Notch pathway activation — a convergent strategy relevant to OSCC where both SDC1 
shedding and Notch signalling drive EMT. [30,46] The central translational gap remains 
the complete absence of registered clinical trials specifically targeting any proteoglycan 
pathway in OSCC, representing an urgent unmet need that warrants dedicated investigator-
initiated Phase I basket trials in recurrent/refractory HNSCC. [33]""".replace('\n', ' ').strip(),

]

# ── Table 3 data ────────────────────────────────────────────────────────────
# Columns: Agent | Target / PG Axis | Mechanism | Cancer Type | Dev. Stage | Key Ref
TABLE3_HEADERS = [
    "Agent / Compound",
    "Target / PG Axis",
    "Mechanism of Action",
    "Cancer Type Studied",
    "Development Stage",
    "Key Reference"
]

TABLE3_ROWS = [
    ["Recombinant decorin\n(core protein)",
     "Decorin / EGFR, TGF-β, VEGFR2",
     "RTK antagonism; TGF-β sequestration; EGFR ubiquitination and degradation; anti-fibrotic",
     "Solid tumours (breast, lung, prostate); OSCC (preclinical)",
     "Preclinical (in vivo xenograft); no current OSCC trial",
     "[53,61,62]"],

    ["Endorepellin\n(perlecan domain V)",
     "Perlecan / α2β1 integrin, VEGFR2",
     "Inhibits endothelial migration and tube formation; anti-angiogenic via integrin-VEGFR2 co-suppression",
     "Solid tumours (preclinical); OSCC (proposed)",
     "Preclinical; no registered trial",
     "[61]"],

    ["Indatuximab ravtansine\n(BT-062; anti-CD138–DM4 ADC)",
     "Syndecan-1 (CD138)",
     "Anti-CD138 antibody conjugated to microtubule inhibitor DM4; selective cytotoxicity in CD138+ cells",
     "Relapsed/refractory multiple myeloma; OSCC (proposed)",
     "Phase I/II (NCT01638936; myeloma); no OSCC trial",
     "[48]"],

    ["Anti-CSPG4 mAb–immunotoxin\n(PE38 conjugate)",
     "CSPG4 / integrin, PDGFR",
     "Selective antibody-mediated cytotoxicity; disrupts integrin-FAK-Src and PDGFR co-activation",
     "Melanoma; HNSCC cell lines (preclinical)",
     "Preclinical; melanoma Phase I ongoing",
     "[32,60]"],

    ["GPC3-targeted CAR-T\n(GPC3-CAR)",
     "Glypican-3 / Wnt, FGF signalling",
     "Chimeric antigen receptor T cells targeting GPC3 overexpressed on tumour surface",
     "Hepatocellular carcinoma; GPC3+ OSCC (proposed)",
     "Phase I/II (HCC; NCT02395250); OSCC: preclinical rationale only",
     "[49,50]"],

    ["Codrituzumab\n(GC33; anti-GPC3 mAb)",
     "Glypican-3 / Wnt",
     "Anti-GPC3 IgG1; ADCC against GPC3-expressing tumour cells; blocks Wnt co-receptor activity",
     "Hepatocellular carcinoma (NCT01507168); GPC3+ OSCC (proposed)",
     "Phase II (HCC); OSCC: no trial",
     "[49]"],

    ["Roneparstat\n(SST0001)",
     "Heparanase-1 / HS proteoglycan axis",
     "Competitive HPSE1 inhibitor; blocks HS chain cleavage and growth factor (FGF-2, VEGF) liberation from ECM",
     "Relapsed multiple myeloma (NCT01764880); OSCC (proposed)",
     "Phase I/II (myeloma); OSCC: no trial; strong rationale from HPSE1 IHC data",
     "[42,44,45]"],

    ["Pixatimod\n(PG545)",
     "Heparanase-1 / HSPG axis; NK cell axis",
     "HS mimetic; HPSE1 inhibition + NK cell activation; dual anti-tumour and immune-stimulatory",
     "Advanced solid tumours (NCT02042781); pancreatic cancer",
     "Phase I completed (solid tumours); OSCC: no trial",
     "[45]"],

    ["INCB7839\n(ADAM10/17 inhibitor)",
     "Syndecan-1 shedding / ADAM10/17",
     "Selective metalloprotease inhibitor; blocks SDC1 ectodomain shedding; reduces HB-EGF and Notch ligand release",
     "HER2+ breast cancer (NCT02022202); OSCC (proposed)",
     "Phase I/II (breast cancer); OSCC: proposed based on SDC1 shedding evidence",
     "[30,46]"],

    ["Versican-targeting aptamer\n/ anti-versican mAb",
     "Versican / CD44, EGFR, immune evasion",
     "Neutralises versican pericellular matrix; restores CD8+ T cell infiltration; blocks CD44/EGFR co-activation",
     "Colorectal cancer; breast cancer; OSCC (preclinical)",
     "Preclinical; no registered clinical trial",
     "[24,56,57]"],
]

# ── Helper functions ─────────────────────────────────────────────────────────

def set_para_text(para, text):
    p = para._p
    for child in list(p):
        tag = child.tag.split('}')[-1] if '}' in child.tag else child.tag
        if tag in ('r', 'hyperlink', 'ins', 'del', 'bookmarkStart', 'bookmarkEnd'):
            p.remove(child)
    r = OxmlElement('w:r')
    t = OxmlElement('w:t')
    t.text = text
    t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve')
    r.append(t)
    p.append(r)

def insert_para_after(ref_el, text, style_id='Normal', italic=False, bold=False, font_size=None):
    new_p = OxmlElement('w:p')
    pPr = OxmlElement('w:pPr')
    pStyle = OxmlElement('w:pStyle')
    pStyle.set(qn('w:val'), style_id)
    pPr.append(pStyle)
    new_p.append(pPr)
    r = OxmlElement('w:r')
    if italic or bold or font_size:
        rPr = OxmlElement('w:rPr')
        if italic:
            rPr.append(OxmlElement('w:i'))
        if bold:
            b = OxmlElement('w:b'); rPr.append(b)
        if font_size:
            sz = OxmlElement('w:sz')
            sz.set(qn('w:val'), str(font_size * 2))
            rPr.append(sz)
        r.append(rPr)
    t = OxmlElement('w:t')
    t.text = text
    t.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve')
    r.append(t)
    new_p.append(r)
    ref_el.addnext(new_p)
    return new_p

def set_cell_text(cell, text, bold=False, font_size=9, wrap=True):
    cell.text = ''
    para = cell.paragraphs[0]
    para.alignment = WD_ALIGN_PARAGRAPH.LEFT
    run = para.add_run(text)
    run.bold = bold
    run.font.size = Pt(font_size)

def shade_row(row, hex_color):
    """Apply background shading to all cells in a row."""
    for cell in row.cells:
        tc = cell._tc
        tcPr = tc.find(qn('w:tcPr'))
        if tcPr is None:
            tcPr = OxmlElement('w:tcPr')
            tc.insert(0, tcPr)
        shd = tcPr.find(qn('w:shd'))
        if shd is None:
            shd = OxmlElement('w:shd')
            tcPr.append(shd)
        shd.set(qn('w:val'), 'clear')
        shd.set(qn('w:color'), 'auto')
        shd.set(qn('w:fill'), hex_color)

# ── Load document ────────────────────────────────────────────────────────────
src = '/tmp/workspace/revised-manuscript/Proteoglycans_OSCC_v5_sec3expanded.docx'
doc = Document(src)

# Identify paragraph indices
# Para 107: 7.2 heading, 108: first body, 109: second body (in original numbering before any edits)
# Re-detect by content
sec72_heading_idx = None
sec72_body_indices = []
for i, p in enumerate(doc.paragraphs):
    t = p.text.strip()
    if '7.2 Therapeutic' in t and p.style.name.startswith('Heading'):
        sec72_heading_idx = i
    if sec72_heading_idx and i > sec72_heading_idx and not p.style.name.startswith('Heading') and t:
        sec72_body_indices.append(i)
    if sec72_heading_idx and p.style.name.startswith('Heading') and '8. FUTURE' in t:
        break

print(f"7.2 heading at index: {sec72_heading_idx}")
print(f"7.2 body paras: {sec72_body_indices}")

# ── Step 1: Replace existing 7.2 body paras with P1 and P2 ─────────────────
# We have 2 existing body paras; replace with P1, P2, then insert P3 after P2

set_para_text(doc.paragraphs[sec72_body_indices[0]], P7_2[0])
set_para_text(doc.paragraphs[sec72_body_indices[1]], P7_2[1])
# Insert P3 after second body para
p2_el = doc.paragraphs[sec72_body_indices[1]]._p
new_p3_el = insert_para_after(p2_el, P7_2[2])
print(f"Replaced 7.2 body paras, inserted P3 ({len(P7_2[2].split())}w)")

# ── Step 2: Insert Table 3 header paragraph after P3 ───────────────────────
tbl_title_el = insert_para_after(new_p3_el,
    "Table 3. Proteoglycan-targeted therapeutic agents: mechanisms, cancer types studied, and development stage.",
    italic=True)
print("Inserted Table 3 title paragraph")

# ── Step 3: Add Table 3 ─────────────────────────────────────────────────────
# Add at end of document, then move to correct position
table = doc.add_table(rows=1 + len(TABLE3_ROWS), cols=len(TABLE3_HEADERS))
table.style = 'Table Grid'
table.alignment = WD_TABLE_ALIGNMENT.CENTER

# Set column widths (total ~17 cm for A4 margins)
col_widths_cm = [3.2, 3.0, 4.0, 3.0, 2.8, 1.5]
for i, width in enumerate(col_widths_cm):
    for row in table.rows:
        row.cells[i].width = Cm(width)

# Header row
header_row = table.rows[0]
shade_row(header_row, '1A237E')  # dark navy
for i, hdr in enumerate(TABLE3_HEADERS):
    cell = header_row.cells[i]
    cell.text = ''
    p = cell.paragraphs[0]
    run = p.add_run(hdr)
    run.bold = True
    run.font.size = Pt(8)
    run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    cell.vertical_alignment = WD_ALIGN_VERTICAL.CENTER

# Data rows
for r_idx, row_data in enumerate(TABLE3_ROWS):
    row = table.rows[r_idx + 1]
    # Alternate shading
    fill = 'EEF2FF' if r_idx % 2 == 0 else 'FFFFFF'
    shade_row(row, fill)
    for c_idx, cell_text in enumerate(row_data):
        cell = row.cells[c_idx]
        cell.text = ''
        p = cell.paragraphs[0]
        run = p.add_run(cell_text)
        run.font.size = Pt(8)
        p.alignment = WD_ALIGN_PARAGRAPH.LEFT
        cell.vertical_alignment = WD_ALIGN_VERTICAL.TOP

# Move table element to after the tbl_title paragraph
tbl_el = table._tbl
tbl_el.getparent().remove(tbl_el)
tbl_title_el.addnext(tbl_el)
print(f"Inserted Table 3 ({len(TABLE3_ROWS)} data rows)")

# ── Step 4: Add footnote line after table ───────────────────────────────────
footnote_text = (
    "ADC = antibody-drug conjugate; ADAM = a disintegrin and metalloproteinase; "
    "ADCC = antibody-dependent cellular cytotoxicity; CAR-T = chimeric antigen receptor T cell; "
    "ECM = extracellular matrix; GF = growth factor; HNSCC = head and neck squamous cell carcinoma; "
    "HPSE1 = heparanase-1; HS = heparan sulphate; HCC = hepatocellular carcinoma; "
    "mAb = monoclonal antibody; NK = natural killer; OSCC = oral squamous cell carcinoma; "
    "PG = proteoglycan; RTK = receptor tyrosine kinase; TGF-β = transforming growth factor beta."
)
insert_para_after(tbl_el, footnote_text, italic=True, font_size=8)
print("Inserted Table 3 footnotes")

# ── Save ────────────────────────────────────────────────────────────────────
out = '/tmp/workspace/revised-manuscript/Proteoglycans_OSCC_v6_final.docx'
doc.save(out)
print(f"\nSaved: {out}")

# ── Word count ───────────────────────────────────────────────────────────────
doc2 = Document(out)
in_refs = False
body_words = 0
sec72_words = 0
in_72 = False
for p in doc2.paragraphs:
    t = p.text.strip()
    if not t: continue
    if 'REFERENCES' in t and p.style.name.startswith('Heading'):
        in_refs = True
    if '7.2 Therapeutic' in t and p.style.name.startswith('Heading'):
        in_72 = True
    if in_72 and '8. FUTURE' in t and p.style.name.startswith('Heading'):
        in_72 = False
    if not in_refs:
        body_words += len(t.split())
    if in_72:
        sec72_words += len(t.split())

print(f"\nSection 7.2 words: {sec72_words}")
print(f"Total body words: {body_words}")

import zipfile, os
z = zipfile.ZipFile(out)
imgs = [r for r in z.namelist() if 'media' in r]
tables_in_doc = len(doc2.tables)
print(f"File size: {os.path.getsize(out)//1024} KB")
print(f"Tables in doc: {tables_in_doc}")
print(f"Images embedded: {imgs}")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/revised-manuscript/build_v6.py'

"""
Build v7_final:
1. Apply all proofread corrections to the v6 docx text
2. Embed Figure 2 after Section 8 (Future Perspectives) before Section 9 (Conclusion)
3. Add Figure 2 legend
4. Save as Proteoglycans_OSCC_v7_final.docx
"""

from docx import Document
from docx.shared import Inches, Pt
from docx.oxml import OxmlElement
from docx.oxml.ns import qn
from docx.enum.text import WD_ALIGN_PARAGRAPH

# ── Proofread corrections dictionary ────────────────────────────────────────
# Format: {old_text: new_text}
# Only substantive corrections — not character-by-character

CORRECTIONS = {

    # 1. SPOCK1 description: "a approximately" → "an approximately"
    "on a approximately 50 kDa core protein":
    "on an approximately 50 kDa core protein",

    # 2. Section 7.2 P1 has ragged line-break spaces from multiline string
    "potential points of  therapeutic intervention":
    "potential points of therapeutic intervention",
    "proteoglycan  biologics":
    "proteoglycan biologics",
    "small-molecule inhibitors of  proteoglycan-modifying enzymes":
    "small-molecule inhibitors of proteoglycan-modifying enzymes",
    "in preclinical solid tumour models  by simultaneously":
    "in preclinical solid tumour models by simultaneously",
    "cytokine sequestration), EGFR  (via receptor":
    "cytokine sequestration), EGFR (via receptor",
    "and degradation), and VEGFR2. [53,62] Endorepellin,":
    "and degradation), and VEGFR2. [53,62] Endorepellin,",

    # 3. Versican: "265-370 kDa" → "265–370 kDa" (en dash)
    "265-370 kDa":
    "265–370 kDa",

    # 4. GPC1-6 → GPC1–6 (en dash for ranges)
    "(GPC1-6)":
    "(GPC1–6)",

    # 5. Consistency: "TGF-beta" → "TGF-β" throughout Section 5 new paragraphs
    "neutralising TGF-beta1 (via direct":
    "neutralising TGF-beta1 (via direct",  # keep as-is — beta here is literal in trial context

    # 6. SLRP expansion paras: "TGF-beta" → "TGF-β"
    "regulates TGF-beta bioavailability":
    "regulates TGF-β bioavailability",
    "TGF-beta-driven cancer-associated":
    "TGF-β-driven cancer-associated",
    "TGF-beta-driven fibroblast activation":
    "TGF-β-driven fibroblast activation",
    "TGF-beta-driven EMT":
    "TGF-β-driven EMT",
    "TGF-beta restraint":
    "TGF-β restraint",
    "TGF-beta1 in the tumour stroma":
    "TGF-β1 in the tumour stroma",
    "TGF-beta-induced epithelial":
    "TGF-β-induced epithelial",
    "TGF-beta1 neutralisation":
    "TGF-β1 neutralisation",
    "TGF-beta1 binding, but with lower":
    "TGF-β1 binding, but with lower",
    "TGF-beta1 drives fibroblast":
    "TGF-β1 drives fibroblast",
    "TGF-beta1 (via direct cytokine sequestration)":
    "TGF-β1 (via direct cytokine sequestration)",
    "antagonising TGF-beta1":
    "antagonising TGF-beta1",  # leave in 7.2 as-is — already uses symbol form nearby

    # 7. "NF-kappaB" → "NF-κB" throughout new paragraphs
    "TLR2/4-NF-kappaB":
    "TLR2/4–NF-κB",
    "TLR2/4 → NF-kappaB":
    "TLR2/4 → NF-κB",
    "NF-kappaB-driven inflammatory":
    "NF-κB-driven inflammatory",
    "NF-kappaB-driven immunosuppressive":
    "NF-κB-driven immunosuppressive",
    "NF-kappaB signalling through TLR2/4":
    "NF-κB signalling through TLR2/4",
    "NF-kappaB pathway":
    "NF-κB pathway",
    "Ras-MAPK and NF-kappaB":
    "Ras-MAPK and NF-κB",
    "NF-kappaB inflammatory":
    "NF-κB inflammatory",
    "activates NF-kappaB":
    "activates NF-κB",
    "TLR2/4-NF-κB activation":
    "TLR2/4–NF-κB activation",

    # 8. "Wnt-beta-catenin" → "Wnt–β-catenin"
    "Wnt-beta-catenin signalling via its CS chains":
    "Wnt–β-catenin signalling via its CS chains",
    "Wnt-beta-catenin and PI3K-Akt":
    "Wnt–β-catenin and PI3K-Akt",
    "Wnt-beta-catenin signalling independently of HS":
    "Wnt–β-catenin signalling independently of HS",
    "Wnt-beta-catenin axis":
    "Wnt–β-catenin axis",

    # 9. "alpha2beta1" → "α2β1"
    "alpha2beta1 and alphavbeta3 integrins":
    "α2β1 and αvβ3 integrins",
    "alpha2beta1 integrin":
    "α2β1 integrin",
    "alpha-SMA":
    "α-SMA",

    # 10. Integrin notation: "alpha3beta1 and alpha4beta1" → "α3β1 and α4β1"
    "alpha3beta1 and alpha4beta1":
    "α3β1 and α4β1",
    "alpha3beta1 and alpha6beta4":
    "α3β1 and α6β4",

    # 11. "PI3K-Akt" consistency (already mostly correct, but a few variants)
    "PI3K-Akt-Akt":
    "PI3K-Akt",

    # 12. Section 3 intro: "PI3K/AKT" → "PI3K/Akt" for consistency with rest of paper
    "PI3K/AKT, and STAT3":
    "PI3K/Akt, and STAT3",

    # 13. Missing hyphen: "cancer stem cell-like" already ok; fix "GPI-anchored" consistency
    "(GPC1–6) that regulate morphogen":
    "(GPC1–6) that regulate morphogen",  # no change needed

    # 14. "CSPG4's" → "CSPG4" possessive is fine, leave

    # 15. Section 7.2 P2 extra spaces from multiline literal
    "NCT01638936), demonstrating acceptable tolerability":
    "NCT01638936), demonstrating acceptable tolerability",

    # 16. Fibromodulin "TGF-beta1" → "TGF-β1"
    "regulation of TGF-beta1 signalling":
    "regulation of TGF-β1 signalling",

    # 17. "NF-κB" already done above; make sure "NF-κB-driven" is consistent:
    "NF-κB-driven immune evasion":
    "NF-κB-driven immune evasion",

    # 18. Extra space in "a approximately"
    "on a approximately":
    "on an approximately",

    # 19. Decorin section: "receptor tyrosine kinase (RTK) antagonist" — already fine

    # 20. Consistency: "heparan sulphate" (British) vs "heparan sulfate" — keep British throughout
    # Most are already "sulphate". Check the one exception in abstract:
    "heparan sulphate proteoglycans (HSPGs)":
    "heparan sulphate proteoglycans (HSPGs)",  # no change

    # 21. "GPC1-3" notation in one place
    "GPC1, -3, -5":
    "GPC1, GPC3, and GPC5",

    # 22. Agrin: "agrin-integrin interactions" — add hyphen properly: already has it

    # 23. Section 3.2 new para: "exosomes that carry syndecan-1 and glypican-1 on their surface"
    # — fine as-is

    # 24. SPOCK1: "approximately 50 kDa" already fixed above

    # 25. Missing Oxford comma fix in one place
    "Wnt, Hedgehog, FGF, and BMP signalling":
    "Wnt, Hedgehog, FGF, and BMP signalling",  # already has Oxford comma

}

def set_para_text(para, text):
    p = para._p
    for child in list(p):
        tag = child.tag.split('}')[-1] if '}' in child.tag else child.tag
        if tag in ('r', 'hyperlink', 'ins', 'del'):
            p.remove(child)
    r = OxmlElement('w:r')
    t_el = OxmlElement('w:t')
    t_el.text = text
    t_el.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve')
    r.append(t_el)
    p.append(r)

def insert_para_after(ref_el, text, italic=False):
    new_p = OxmlElement('w:p')
    pPr = OxmlElement('w:pPr')
    pStyle = OxmlElement('w:pStyle')
    pStyle.set(qn('w:val'), 'Normal')
    pPr.append(pStyle)
    new_p.append(pPr)
    r = OxmlElement('w:r')
    if italic:
        rPr = OxmlElement('w:rPr')
        rPr.append(OxmlElement('w:i'))
        sz = OxmlElement('w:sz'); sz.set(qn('w:val'), '18'); rPr.append(sz)
        r.append(rPr)
    t_el = OxmlElement('w:t')
    t_el.text = text
    t_el.set('{http://www.w3.org/XML/1998/namespace}space', 'preserve')
    r.append(t_el)
    new_p.append(r)
    ref_el.addnext(new_p)
    return new_p

# ── Load document ────────────────────────────────────────────────────────────
src = '/tmp/workspace/revised-manuscript/Proteoglycans_OSCC_v6_final.docx'
doc = Document(src)

# ── Apply text corrections ───────────────────────────────────────────────────
corrections_applied = 0
for para in doc.paragraphs:
    original = para.text
    if not original.strip():
        continue
    new_text = original
    for old, new in CORRECTIONS.items():
        if old in new_text:
            new_text = new_text.replace(old, new)
    if new_text != original:
        set_para_text(para, new_text)
        corrections_applied += 1

# Also fix in table cells
for table in doc.tables:
    for row in table.rows:
        for cell in row.cells:
            for para in cell.paragraphs:
                original = para.text
                if not original.strip(): continue
                new_text = original
                for old, new in CORRECTIONS.items():
                    if old in new_text:
                        new_text = new_text.replace(old, new)
                if new_text != original:
                    # For table cells, set text via run
                    for run in para.runs:
                        for old, new in CORRECTIONS.items():
                            if old in run.text:
                                run.text = run.text.replace(old, new)

print(f"Text corrections applied to {corrections_applied} paragraphs")

# ── Embed Figure 2 after Section 8 body, before Section 9 heading ───────────
sec9_idx = None
for i, p in enumerate(doc.paragraphs):
    if '9. CONCLUSION' in p.text and p.style.name.startswith('Heading'):
        sec9_idx = i
        break

print(f"Section 9 heading at paragraph index: {sec9_idx}")

# Get the last paragraph before section 9
sec8_last_el = doc.paragraphs[sec9_idx - 1]._p
sec9_el = doc.paragraphs[sec9_idx]._p

# Figure 2 legend text
fig2_legend = (
    "Figure 2. Context-dependent dual roles of proteoglycans in OSCC: tumour suppressors versus "
    "tumour promoters. Left panel (green): tumour-suppressive proteoglycans — decorin, lumican, "
    "PRELP, fibromodulin, and intact perlecan — exert anti-tumour effects through TGF-β "
    "sequestration, EGFR degradation, MMP-14 inhibition, basement membrane anchoring, and "
    "generation of the anti-angiogenic fragment endorepellin. These converge on outcomes including "
    "apoptosis, reduced invasion, and suppressed angiogenesis (lower left). Right panel (red): "
    "tumour-promoting proteoglycans — versican, biglycan, shed syndecan-1, SPOCK1, CSPG4, and "
    "heparanase-1 — drive invasion, immune evasion, and angiogenesis through CD44/EGFR "
    "co-activation, TLR2/4–NF-κB signalling, paracrine growth factor delivery, and CXCR4/PI3K "
    "activation (lower right). Central strip (purple): molecular switches — heparanase-1 "
    "upregulation, SDC1 ectodomain shedding, miR-23a-3p-mediated PRELP downregulation, nuclear "
    "decorin mislocalisation, SLRP stromal loss, and ADAMTS loss — shift the balance (central "
    "ellipse) from the suppressive to the promoting state. Therapeutic implications for each "
    "arm are summarised at the bottom. "
    "BM = basement membrane; CAF = cancer-associated fibroblast; ECM = extracellular matrix; "
    "EMT = epithelial–mesenchymal transition; GF = growth factor; HPSE1 = heparanase-1; "
    "MMP = matrix metalloproteinase; OSCC = oral squamous cell carcinoma; "
    "SLRP = small leucine-rich proteoglycan; TGF-β = transforming growth factor beta; "
    "TME = tumour microenvironment."
)

# Spacer before figure
spacer1_el = insert_para_after(sec8_last_el, '')

# Add figure using doc.add_picture (appends to body end), then move
fig2_para = doc.add_paragraph()
fig2_para.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = fig2_para.add_run()
run.add_picture('/tmp/workspace/revised-manuscript/Figure2_DualRole_PG_OSCC.png',
                width=Inches(6.8))

# Move figure paragraph to after spacer1
fig2_el = fig2_para._p
fig2_el.getparent().remove(fig2_el)
spacer1_el.addnext(fig2_el)

# Legend after figure
legend_el = insert_para_after(fig2_el, fig2_legend, italic=True)

# Spacer after legend
insert_para_after(legend_el, '')

print("Figure 2 embedded with legend")

# ── Save ────────────────────────────────────────────────────────────────────
out = '/tmp/workspace/revised-manuscript/Proteoglycans_OSCC_v7_final.docx'
doc.save(out)
print(f"\nSaved: {out}")

import zipfile, os
z = zipfile.ZipFile(out)
imgs = [r for r in z.namelist() if 'media' in r]
print(f"File size: {os.path.getsize(out)//1024} KB")
print(f"Images embedded: {len(imgs)} — {imgs}")
print(f"Tables: {len(doc.tables)}")

# Final word count
doc2 = Document(out)
in_refs = False
body = 0
for p in doc2.paragraphs:
    t = p.text.strip()
    if not t: continue
    if 'REFERENCES' in t and p.style.name.startswith('Heading'): in_refs = True
    if not in_refs: body += len(t.split())
print(f"Final body word count: {body}")