Cervical cancer ranks as the fourth leading cause of cancer-related deaths among women globally, with over 604,127 new cases and 341,831 deaths reported in 2020 (1). Persistent infection with high-risk human papillomavirus (HR-HPV) is the main pathogenic factor for cervical cancer and intraepithelial neoplasia (CIN), HR-HPVs have been detected in 99.7% of cervical cancers (2). Although preventive HPV vaccination and screening programs have been implemented, the global burden of cervical cancer remains significant, particularly in regions with limited access to these measures (3). HPV-infected cells decrease interferon secretion, disrupting a crucial mechanism for antiviral immune stimulation (4). Although most HPV infections are cleared or become latent, those that persist can progress to CIN (5). CIN 1 (low-grade, mild dysplasia) is a benign cervical dysplasia state associated with viral replication, and conservative treatment is recommended. Because it is expected that 70% -90% of CIN1 lesions will subside within 2-3 years (6). Untreated CIN3 (high-grade, severe dysplasia) can develop into invasive cervical cancer, and less than 20% of which have been proven to regress (7). Timely detection and treatment of CIN or early-stage cervical cancer yield better clinical outcomes than treating advanced-stage patients. However, early diagnostic biomarkers are currently lacking, and most cancer cases are detected in the later stages (8, 9). In addition, standard treatments for cancer include surgery, radiation therapy, and platinum-based chemotherapy (10). Recent statistical data shows that late stage and recurrent cases have poor response to these interventions, with a five-year survival rate of approximately 17% for metastatic diseases (11). The introduction of targeted therapies and immune checkpoint inhibitors provides new avenues for improving the prognosis of these late-stage patients (12). Therefore, specific biomarkers for the diagnosis and prognosis of CIN and early cervical cancer urgently need to be explored.

This study aims to analyze tumors by examining genes that are closely associated with overall survival (OS) using data from the GSE63514, GSE7803, GSE9750, and TCGA-CESC databases. The top 20 core genes were screened out, these are KIFC1, KIF14, HELLS, TK1, GINS2, WDR76, PCNA, DSG2, MCM5, SYNGR3, APOBEC3B, CHAF1B, TMPO, NUP62CL, RIBC2, PLA2G7, ARHGAP4, TFRC, GAD1, SPP1. Notably, transferrin receptor (TFRC) emerged as a prioritized candidate due to its dual role in cellular iron homeostasis and oncogenic signaling. However, the underlying mechanism of TFRC in the occurrence and malignant progression of cervical cancer is still unclear. Among these, we ultimately selected the TFRC gene as the primary focus of our research.

The TFRC gene encodes two distinct types of transferrin receptors, namely TFR1 and TFR2, which serve as the most crucial receptor-mediated regulatory factors for cellular iron uptake, as highlighted in the findings of Qin et al. (13). Iron is an important micronutrient and is central to various biological processes including oxygen transport, DNA replication, and redox reactions (14). The intricate interactions between iron metabolism, ferroptosis, and tumorigenesis have recently attracted great attention in cancer biology (15). It is worth noting that ferroptosis is an iron dependent programmed cell death (PCD) characterized by the accumulation of reactive oxygen species (ROS). This accumulation can be offset by iron chelators and lipophilic antioxidants (16). Several studies have documented that the TFRC gene is abnormally overexpressed in various human tumors, including but not limited to liver cancer, glioblastoma, and colorectal cancer. The expression levels of TFRC are significantly elevated in human tissues, particularly in metastatic tumors, and this overexpression is directly correlated with poor prognosis (17, 18; W. 19, 20). However, the exact role of TFRC in the development and progression of cervical cancer remains unclear.

In light of these findings, this study harnessed extensive sample data from various databases, complemented by biochemical experiments, to thoroughly investigate the expression levels and potential clinical applications of TFRC in the context of cancer. Additionally, we employed advanced bioinformatics techniques to delve into the underlying mechanisms of TFRC and its significant role in immunotherapy, ultimately providing valuable recommendations for enhancing cancer treatment strategies.

Cervical cancer is the fourth most common type of cancers among women worldwide (21). While preventive strategies including HPV vaccination, routine screening protocols, and timely intervention for screen-detected preinvasive lesions have significantly reduced disease burden, the World Health Organization’s 2020 global elimination initiative sets ambitious 90-70-90 targets. This comprehensive strategy aims to reduce age-standardized incidence rates below 4 per 100,000 women annually through scaled-up prevention program (22). Nevertheless, the persistent clinical challenges in differentiating progressive cervical intraepithelial neoplasia (CIN) from transient HPV infections underscore the urgent need for robust molecular biomarkers enabling precise diagnosis and prognostic stratification. Our multi-cohort analysis systematically interrogated genomic datasets (GSE63514, GSE7803, GSE9750) complemented by TCGA cervical cancer profiles to identify survival-associated signatures. Through integrated bioinformatics pipeline analysis, we identified 20 hub genes (KIFC1, KIF14, HELLS, TK1, GINS2, WDR76, PCNA, DSG2, MCM5, SYNGR3, APOBEC3B, CHAF1B, TMPO, NUP62CL, RIBC2, PLA2G7, ARHGAP4, TFRC, GAD1, SPP1) demonstrating strongest correlation with overall survival (OS). Notably, transferrin receptor (TFRC) emerged as a prioritized candidate due to its dual role in cellular iron homeostasis and oncogenic signaling. However, the underlying mechanism of TFRC in the occurrence and malignant progression of cervical cancer is still unclear.

Transferrin receptor (TFRC) is a vital membrane protein that plays a critical role in cellular iron uptake, which is essential for various cellular processes, including growth and proliferation(Wenjing 19). Recent studies have shown that TFRC is closely associated with the development and progression of multiple cancer types. For instance, studies have shown that TFRC expression is significantly elevated in various cancer types, including breast, gastric, and colorectal cancers, where it correlates with poor prognosis and aggressive tumor behavior (23–25). Our preliminary findings revealing TFRC’s prognostic significance in cervical carcinogenesis warrant focused investigation into its pathobiological mechanisms and clinical translation potential.

Systematic pan-cancer analysis of unified TCGA datasets across 33 malignancies revealed distinct TFRC expression patterns. Our results showed that TFRC expression was higher in 12 tumors, including BLCA, BRCA, CESC, CHOL, COAD, ESCA, GBM, HNSC, LIHC, LUSC, STAD and UCEC (fold change >2.0, FDR<0.05). In contrast, it was expressed lower in KIRP, LUAD, PCPG, PRAD and THCA (p<0.01). Meanwhile, the expression of TFRC was correlated with pathological stage, lymph node metastasis, malignant degree of cervical lesions and HPV infection status. We confirmed the higher expression of TFRC in cervical cancer tissues than in normal cervix tissues, and its expression was higher in HSIL than in normal tissues using IHC staining. Higher expression was associated with reduced OS (p = 0.024), DSS (p = 0.009) and PFI (p = 0.007) in CESC. In different clinical stages, pathological T stages, and pathological N stages, higher TFRC expression was significantly associated with worse survival for OS and DSS. We constructed a nomogram model, TFRC contributed significantly to the prognosis and exhibited good predictive power for the OS and the DSS. Similarly, gastric cancer and prostate cancers models have shown that TFRC overexpression is associated with increased tumor incidence and aggressiveness, suggesting a direct link between iron uptake and cancer progression (26, 27). Sai Han et al. reported that TFRC were confirmed to be potential plasma diagnostic markers for Lymph node metastasis and lymphatic vasculature space infiltration in cervical cancer patients (28). Finally, the correlation between immune cell infiltration and TFRC expression was analyzed. We confirmed that immunosuppression in cervical cancer was closely related to high TFRC expression. The relationship between TFRC and immune cell function is a critical aspect of the tumor microenvironment (TME) that influences cancer progression and treatment outcomes. In the context of cancer, the expression of TFRC on immune cells can significantly affect their functionality and the overall immune response against tumors.

Understanding the mechanisms governing TFRC expression and function is crucial for developing therapeutic strategies targeting iron metabolism in cancer and other diseases. In cancer cells, due to the large amount of iron required for cell proliferation, the expression of TFRC often increases. Fu Wang et al. found that the absence of TFRC significantly impaired cell proliferation and migration in vitro, and significantly inhibited the growth and metastasis of HCC in vivo, while overexpression of TFRC had the opposite effect (29). Crawford Currie et al. reported that Colony growth suppression was often associated with the degree of simultaneous decrease in TFRC expression in prostate cancer (30). Beung-Chul Ahn et al. found that higher baseline TFRC levels predicted a favorable response to nivolumab in NSCLC with low PD-L1 expression (31). Moreover, the mechanisms underlying the regulation of TFRC expression in cancer cells are complex and involve various signaling pathways. For example, the transcription factor hypoxia-inducible factor (HIF) has been implicated in the upregulation of TFRC in response to low oxygen levels, a common feature in the tumor microenvironment. This adaptive response enables cancer cells to maintain iron homeostasis under hypoxic conditions, further promoting their survival (32). Additionally, mutations in oncogenes and tumor suppressor genes, such as TP53, have been shown to alter iron metabolism and TFRC expression, contributing to the malignant phenotype (33). Guofei Feng et al. reported that TfR was overexpressed in nasopharyngeal carcinoma, and TFRC knockdown inhibited nasopharyngeal carcinoma progression by suppressing the PI3K/Akt/mTOR signaling pathway (34). In studies of pancreatic and colon cancer cells, TFRC has been shown to modulate the MAPK signaling pathway, contributing to increased cell viability and resistance to apoptosis (35). Notably, the mechanistic basis of TFRC in cervical carcinogenesis and malignant progression remains unelucidated. To address this critical knowledge gap, we will undertake a pioneering study to comprehensively investigate its iron-dependent oncogenic mechanisms through integrated multi-omics approaches and functional validation models.

TFRC has emerged as a significant target in cancer therapy due to its overexpression in various malignancies, which is often associated with increased cellular iron uptake necessary for rapid tumor growth. The exploration of TFRC as a target has gained momentum in recent years, with numerous studies investigating its implications in both small molecule drug development and gene therapy applications aimed at enhancing therapeutic efficacy and specificity in cancer treatment. Some studies have demonstrated that transferrin-conjugated nanoparticles can effectively deliver chemotherapeutic agents directly to tumor cells, thereby minimizing systemic toxicity and enhancing therapeutic outcomes (25). Additionally, the use of small molecules that inhibit TFRC function has been explored as a potential strategy to disrupt iron homeostasis in cancer cells, thereby inducing ferroptosis, a form of regulated cell death characterized by iron-dependent oxidative stress (36). Moreover, the development of DNA aptamers that specifically bind to TFRC has opened new avenues for targeted therapy. These aptamers can serve as carriers for cytotoxic drugs, enhancing their selective uptake by cancer cells while reducing off-target effects (24). The high affinity and specificity of these aptamers for TFRC make them ideal candidates for the development of novel cancer therapeutics that could improve patient outcomes. Furthermore, studies have indicated that the combination of TFRC-targeting agents with existing chemotherapy regimens can enhance the overall efficacy of treatment, particularly in resistant cancer types such as breast and prostate cancer (27, 37). Recent advancements in nanoparticle technology have facilitated the development of TFRC-targeted gene delivery systems, which can effectively transport therapeutic nucleic acids to cancer cells. These systems can be engineered to enhance cellular uptake through receptor-mediated endocytosis, leveraging the overexpression of TFRC in tumor cells (38). Moreover, the use of CRISPR/Cas9 technology to edit TFRC expression levels in cancer cells has shown potential in preclinical models, suggesting that manipulating TFRC could alter tumor growth dynamics and response to therapy (39). In conclusion, the potential of TFRC as a target for both small molecule drugs and gene therapy represents a significant advancement in cancer treatment. The ongoing research into TFRC-targeted therapies could lead to the development of more effective and personalized treatment options for patients, particularly those with iron-dependent malignancies. As our understanding of TFRC’s role in cancer biology continues to evolve, it is likely that innovative therapeutic strategies will emerge, offering new hope for improved patient outcomes.

While this investigation provides novel insights into TFRC’s oncogenic role, three key limitations merit consideration: The current mechanistic understanding remains incomplete due to predominant reliance on bioinformatics analyses and preliminary experimental validation, necessitating integrated multi-omics approaches to fully delineate TFRC’s iron-mediated molecular circuitry. Furthermore, the restricted sample size in our single-center retrospective cohort introduces potential selection bias, limiting extrapolation to broader populations. Most critically, the therapeutic potential of TFRC-targeted strategies remains biologically unsubstantiated in the absence of preclinical models and early-phase clinical trials. To address these gaps, we plan to expand validation through multi-institutional cohorts, mechanistically dissect TFRC’s tumorigenic pathways via CRISPR-Cas9 screening coupled with spatial transcriptomics, and evaluate therapeutic efficacy using TFRC-specific PROTAC degraders in patient-derived xenograft models. These concerted efforts aim to bridge fundamental discoveries to clinical translation, potentially establishing TFRC as both prognostic biomarker and therapeutic vulnerability in cervical oncology.

In summary, based on GSE63514, GSE7803, GSE9750 and TCGA data, this study found that TFRC was highly expressed in cervical cancer, which was closely related to the prognosis of tumor and OS, DSS, and PFI. We confirmed the higher expression of TFRC in cervical cancer than in normal cervix tissues and HSIL using IHC staining. Meanwhile, the expression of TFRC was correlated with pathological stage, lymph node metastasis, malignant degree of cervical lesions and HPV infection status. Besides, we constructed a nomogram model that TFRC contributed significantly to the prognosis and exhibited good predictive power for the OS and the DSS. Finally, We confirmed that immunosuppression in cervical cancer is closely related to high TFRC expression. Thus, TFRC has certain diagnostic and prognostic value in cervical cancer, and may become a prognostic marker of cervical cancer.