Oral Cytology, Biopsy and Other Oral Cancer Diagnostics

1
Oral Cytology, Biopsy and Other Oral Cancer
Diagnostics
2
Oral Cancer Diagnostics

• With oral cancer in order to achieve a good
  clinically outcome, early detection and adequate
  early treatment are absolutely necessary. As the
  size of the tumor and the extent of its spread
  increases, the chances for a good prognosis
  lessens expeditiously.
• Biopsy is the only method of definitively
  diagnosing an oral cancer.
• However, immediate biopsy of every ill-defined
  lesion may not be practical or in some cases
  indicated.

3
Oral Cytology

• Exfoliative cytology has been used for decades as
  a simple, reliable and acceptable technique to
  support clinical judgment in helping
  differentiate benign and malignant lesions.
• Many of the principles, concepts and techniques
  used in exfoliative cytology are applied to the
  newer technique of oral brush biopsy, which will
  be discussed later in this lecture.
• However, exfoliative cytology (and brush biopsy)
  are adjuncts to not a substitute for biopsy.

4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
Cytological Criteria for Malignant Cells

• 1. Enlarged nuclei
• 2. Variation in nuclear size and shape
  (pleomorphism)
• 3. Prominent and irregular nuclear border
• 4. Increased nuclear-cytoplasmic ratio (decreased
  cytoplasm)

12
Cytological Criteria for Malignant Cells Continued

• 5. Multiple prominent and irregular nucleoli
• 6. Hyperchromatism (increased nucleoproteins)
• 7. Abnormal chromatin pattern and distribution
• 8. Discrepancy in maturation (extreme variations)

13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
Use of Cytological Reports

• If a clinical suspension remains in face of a
  negative or atypical report, further smears or a
  biopsy should be performed.
• A suspicious report indicates a definite need to
  establish a definitive diagnosis via biopsy
  immediately.
• When a smear contains cells consistent with
  malignancy, obviously a biopsy is mandatory to
  confirm the diagnosis.

18
Biopsy

• No tumor should be treated without confirmation
  of the diagnosis by histological examination of
  the tissue.
• For intraoral malignancies there is no good
  evidence from human studies that a properly
  performed biopsy will encourage the spread of a
  tumor locally, or by the lymphatics or blood
  vessels.

19
Biopsy

• In general, the most satisfactory biopsy of an
  intraoral lesion is the incisional biopsy where a
  small portion of the lesion is removed for
  microscopic examination.
• However, incisional biopsy of a small lesion may
  distort its appearance and consistency and then
  ideally the clinician who will apply the
  definitive treatment should see the lesion so
  he/she can judge the extent of resection or
  irradiation to be instituted.

20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
Biopsy

• If the lesion is small, then the treatment of
  choice is excisional biopsy, where the complete
  lesion is removed at once with adequate borders
  of normal tissue.
• Whether the biopsy specimen is obtained by
  incisional or excisional biopsy, the surgical
  specimen should be placed in an appropriate
  fixative immediately.

24
(No Transcript)
25
Biopsy Fixation

• 10 buffered neutral formalin is considered the
  best general fixative for pathological specimens
  because of the following
• It preserves the widest range of structures
• It requires a short fixation time
• It can be used for long-term storage
• It penetrates rapidly and evenly without
  overhardening

26
Biopsy Fixation

• As noted previously the specimen should be placed
  in the fixative immediately.
• The specimen should be completely submerged in 5
  to 10 times its volume of fixative.

27
Punch Biopsy Technique
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
Fine Needle Biopsy

• This is a good accurate technique for
  differentiating benign from malignant lesions in
  lymph nodes and it is also useful for salivary
  gland lesions.
• Armamentarium includes a 22-gauge needle and a
  special holder for a 10-20 ml syringe.
• Anesthesia is usually not required. The needle
  is placed in the lesion and cells are aspirated
  into the syringe.
• The specimen is prepared by cytologic techniques.

32
(No Transcript)
33
Toluidine Blue

• Toluidine blue is a metachromatic dye of the
  thiazine group that has been effectively used as
  a nuclear stain because of its binding to DNA.
• While most epithelial surfaces stain blue after
  the application of a 1 toluidine blue solution,
  the stain is lost after application of a 1
  acetic acid solution. However, premalignant and
  malignant erythematous lesions are not
  decolorized by the acid.
• Utilization of this technique has been show to
  aid early recognition and accelerate biopsy,
  diagnosis and treatment.

34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
Brush Biopsy

• The brush biopsy technique was not new (i. e.
  lung/bronchial brush biopsies) when it was
  applied to the oral tissues in the late 1990s
  and marked as the Oral CDx brush biopsy with the
  ADAs seal of acceptance.

39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52
Oral CDx Study Group Findings as Reported in JADA

• In their study of 945 patients, they reported a
  sensitivity of 100 and as specificity of 100
  for positive results and 92.9 for atypical
  results.
• They concluded that All Oral CDx atypical
  and positive results should be referred for
  scalpel biopsy and histology to completely
  characterize the lesion.

53
More Recent Data from OralScan Laboratories, Inc.
(Oral CDx)

• In a letter to the AAOMP, dated August 10, 2001,
  they noted that they had received over 50,000
  specimens from general dentists.
• Approximately 6,000 of those specimens were
  identified as positive or atypical.
• Surveys indicated that patients identified with
  positive or atypical reports were almost all
  referred for scalpel biopsies.

54
More Recent Date .Continued

• Their most recent data indicated that of the
  6,000 scalpel biopsies triggered by the results
  of the CDx tests, 2,000 cases of dysplasia,
  carcinoma in situ and squamous cell carcinoma
  were confirmed for a Positive Predictive Value of
  30 . They stated that this PPV compares very
  favorably with other cost-effective and medically
  useful tests such as the cervical Pap smear, PSA
  testing or routine mammography.

55
More Recent Data.Continued

• As of the date of their letter they stated that
  our clinical experience to date from over 50,000
  specimens has also been consistent with the gt96
  sensitivity and gt90 specificity reported in the
  pivotal clinical trial. Over the last 18 months,
  we have received reports of 5 Oral CDx false
  negatives.

56
Oral CDx Study Group Findings

• All Oral CDx atypical and positive results
  should be referred for scalpel biopsy and
  histology to completely characterize the lesion.

57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
(No Transcript)
67
(No Transcript)
68
(No Transcript)
69
(No Transcript)
70
VELScope

• Called a Visually Enhanced Lesion Scope
  (VELScope), this simple hand-held device emits a
  cone of blue light into the mouth that excites
  various molecules within our cells, causing them
  to absorb the light energy and re-emit it as
  visible fluorescence.
• The VELScope allows the dentist to shine the
  light on a suspicious sore in the mouth and look
  through an attached eyepiece and watch for
  changes in color

71
VELScope

• Normal oral tissue emits a pale green
  fluorescence, while potentially early tumor, or
  dysplastic, cells appear dark green to black.
• The first report (Aug. 2006) evaluated 50 tissue
  sites from 44 patients. Reading the fluorescence
  patterns translated into a 100 specificity and
  a 98 sensitivity for oral dysplasia and
  cancers. To date no further data is available.
  (Sensitivity refers to how well a test correctly
  identifies people who have a disease, while
  specificity characterizes the ability of a test
  to correctly identify those who are well).