Occurrence of epithelial dysplasia in oral leukoplakia. Analysis and follow-up study of 12 cases

4-nitroquinoline-1-oxide (4NQO) induced oral carcinogenesis: A systematic literature review

OBJECTIVE

Based on a critical review of published studies, we aimed to develop a good practice guide for using 4-nitroquinoline-1-oxide (4NQO) as an inducer of oral carcinogenesis in Wistar rats.

DESIGN

A systematic search was performed on Medline Ovid, PubMed, Embase, Web of Science, and Scopus databases. The SYRCLE's risk of bias tool was used to assess the quality of the studies.

RESULTS

Thirty-five articles met the selection criteria; 22 (62.9%) of them administered 4NQO systemically in drinking water, with a mean concentration of 30.2 ppm (SD±15.9) and during a mean period of 20.8 (SD±7.8) weeks. The other 13 (37.1%) studies performed topical applications of 4NQO painting the oral mucosa of the animals three times a week (100%) with a mean period of administration of 16.8 (SD±7.0) weeks. Different 4NQO concentrations used for other periods achieved significant tumor development. Most studies didn't perform quantitative clinical analysis, and the histopathological diagnosis/grading criteria varied considerably.

CONCLUSIONS

A poor description of solution care, adverse effects, and the number of losses were observed, and the reporting of these features needs to be improved. Suggestions to guide the development of future research are provided.

Critical update, systematic review, and meta-analysis of oral erythroplakia as an oral potentially malignant disorder

Background

Oral erythroplakia has been classically considered as the potentially malignant disorder with the highest rate of malignant development into squamous cell carcinoma. This critical systematic review and meta‐analysis aim to estimate the malignant development rate of oral erythroplakia and identify the associated risk factors.

Methods

We performed a bibliographic search in PubMed, Scopus, Web of Science, Embase, and LILACS, with keywords “erythroplakia,” “erythroplasia,” “malignant transformation,” “malignant development,” “malignization,” “carcinogenesis,” “oral cancer,” “oral squamous cell carcinoma,” “mouth neoplasm,” and “prognosis.” Meta‐analysis was conducted using a random‐effects model.

Results

Ten observational studies with 441 patients met the inclusion criteria, whose mean malignant development rate was 12.7% and with a mean follow‐up period of patients of 6.66 years. In the initial biopsy, 42.8% of oral erythroplakia were already squamous cell carcinoma. The buccal mucosa was the most frequent location of oral erythroplakia, but the floor of the mouth was the most common site of malignant development. All patients who underwent malignant development showed epithelial dysplasia on the initial diagnostic biopsy.

Conclusion

Overall malignant development rate of OE in the meta‐analysis was 19.9%. We could not associate any specific clinicopathological feature with the malignant development. The presence of epithelial dysplasia in the initial biopsy remains the worst prognostic factor. Further observational studies on OE are needed, with well‐established diagnostic criteria and good clinical follow‐up, in order to identify the true risk of malignant development of oral erythroplakia and the related risk factors.

Prophylactic effect of topical (slow-release) and systemic curcumin nano-niosome antioxidant on oral cancer in rat

BACKGROUND

Oral malignancies have a significant effect on the quality of life among the affected patients. Curcumin is an antioxidant with a low bioavailability in the target tissue. Niosomes are carriers of increasing the therapeutic effects of drugs and reducing their side effects. This study aimed to determine the effective dose of curcumin niosome in the culture and then to compare its prophylactic effect in the form of mouthwash with that of its injectable form on oral cancer in rats.

METHODS

This was an in-vitro and in-vivo study. Firstly, KB oral cancer cells and human umbilical vein endothelial cells (HUVEC) were treated in separate groups with free curcumin, curcumin-loaded niosomes, and the unloaded niosomes at four doses of 4, 8, 16, and 32 μg. The study rats were then divided into the following four groups: 1) no intervention, 2) only carcinogenic substance, 3) carcinogenic substance with curcumin-loaded niosome injection, and 4) carcinogenic substance with a mouthwash containing niosome.

RESULTS

At the cellular level, a dose of 16 μg after 24 h was selected as an effective dose. In the animal phase, the use of injectable curcumin niosome was observed to significantly prevent the development of severe forms of dysplasia.

CONCLUSIONS

In this in-vitro and in-vivo study, curcumin-loaded niosome was effective in preventing the development of severe forms of dysplasia and the inhibition of the growth of cancer cells.

Oral epithelial dysplasia: Recognition, grading and clinical significance

Histopathological grading of epithelial dysplasia remains the principal laboratory method for assessing the risk of malignant transformation in oral potentially malignant disorders (OPMDs). Current views on the molecular pathogenesis and histological interpretation of the features of epithelial dysplasia are described, and the use of grading systems for epithelial dysplasia is discussed. Changes to the current 2017 WHO criteria for diagnosis are proposed with emphasis on the architectural features of epithelial dysplasia. The predictive values of three-grade and binary systems are summarised, and categories of epithelial dysplasia are reviewed, including lichenoid and verrucous lesions, keratosis of unknown significance, HPV-associated dysplasia, differentiated and basaloid epithelial dysplasia. The implications of finding epithelial dysplasia in an oral biopsy for clinical management are discussed from the pathologists' viewpoint.

Management of Oral Potentially Malignant Disorders

Patients with oral potentially malignant disorders (OPMDs), including oral leukoplakia and erythroplakia, proliferative verrucous leukoplakia, oral submucous fibrosis, and oral lichen planus/lichenoid lesions can be challenging to manage. A small proportion will undergo cancer development and determining a patient's cancer risk is key to making management decisions. Yet, our understanding of the natural history of OPMDs has not been fully elucidated, and a precision approach based on the integration of numerous predictive markers has not been validated by prospective studies. Evidence-based health promotion by clinicians and healthcare systems is not embraced universally. Medical and surgical interventions evaluated by rigorous research measuring important endpoints, such as cancer development, mortality, or survival are difficult and expensive to run. Most of these studies employ non-ideal surrogate endpoints and have deep methodologic flaws. Diagnostic criteria for enrolling research subjects are not uniform, and patients with the highest risk for cancer development comprise small proportions of those enrolled. Few studies explore quality of life and patient preferences. It is time to rethink how we approach the management of these patients, across each OPMD, and considering the healthcare infrastructure and cost effectiveness. Global networks with well-characterized patient populations with OPMDs and well-designed interventional trials using validated outcome measures are needed.

Current challenges and the diagnostic pitfalls in the grading of epithelial dysplasia in oral potentially malignant disorders: A review

Oral cancer is one of the common cancers in the world causing high morbidity. Development of cancer is preceded by certain asymptomatic clinical lesions and conditions all together known as 'oral potentially malignant disorders'. Histologically they are represented by the term 'oral epithelial dysplasia'. The degree of severity of dysplasia is determined in the form of 'grade'. Despite the existence of several grading systems proposed by various scholars, it is still a challenging task for the Pathologists to grade dysplasia accurately for the proper diagnosis of the disease and to follow preferable treatment plans. This review aims to focus on the current challenges and the diagnostic pitfalls in the grading of oral epithelial dysplasia in various oral potentially malignant disorders.

Long-term follow-up of oral epithelial dysplasia: A hospital based cross-sectional study

Background/purpose

Oral epithelial dysplasia (OED) is characterized histopathologically by cellular and morphological changes that remain the single most important factor predicting risk for subsequent development of invasive neoplasia. Hence the aims of the present study were to determine the rate of malignant change of OED in a group of patients followed-up for a number of years, and hence determine factors likely to influence this malignant change, and to describe the clinical characteristics of patients who developed recurrence of OED and second dysplastic lesions.

Materials and methods

This is hospital based cross-sectional study of all biopsy reports with histologically confirmed OED between 2012 and 2018 were retrospectivelly reviewed.

Results

A total of 359 patients with histologically confirmed OED were reviewed, twenty (5.5%) of the 359 patients developed an invasive squamous cell carcinoma (SCC) of the oral mucosa over a period of 2 to 274 months with mean transformation time of 3.3 years.

Conclusion

The high risk of malignant transformation of OED seems to be related to patients older than 50 years when lesions were on the floor of mouth with severe dysplastic changes.

Medical practitioners' educational competence about oral and oropharyngeal carcinoma: a systematic review and meta-analysis

Medical practitioners' (MP) role is pivotal in primary prevention, early diagnosis, prompt referral and effective management of oral and oropharyngeal carcinomas (OC/OPC), which raises the importance of their effective OC/OPC education at all levels of medical education. The purpose of this systematic review was to summarise the available scientific evidence about their educational competence in dealing with OC/OPC. We made a systematic search of papers in the English language in MEDLINE, Scopus, Cochrane Library CENTRAL and CINAHL databases from their inception until December 2018. Overall, 23 cross-sectional and three interventional studies have been selected for the systematic review and 18 of these were included in the meta-analyses. Excluding tobacco use (synthesised estimate of 95% of respondents identified tobacco as an OC/OPC risk factor, 95% CI of synthesised estimate 92% to 97%) and alcohol consumption (65%, 95%CI 52% to 77%), less than half of MP (approximately) were knowledgeable about important OC/OPC risk factors including human papilloma virus (42%, 95% CI 30% to 54%), poor diet (34%, 95% CI 17% to 54%), and advancing age (45%, 95% CI 21% to 70%). There was a low to moderate level of awareness among MP regarding common precancerous oral lesions involving leukoplakia (56%, 95% CI 32% to 79%), erythroplakia (30%, 95% CI 8% to 58%), and oral lichen planus (13%, 95% CI 0 to 41%). Moderate knowledge was also recorded about frequent sites of OC development involving the tongue (48%, 95% CI 33% to 64%) and floor of the mouth (37%, 95% CI 19% to 57%). Most MP enquired about tobacco use (86%, 95% CI 74% to 96%), and alcohol consumption (73%, 95% CI 47% to 94%) during history taking, and expressed willingness to be given supplementary OC/OPC education (78%, 95% CI 54% to 96%), as well. With regard to the incidence of intraoral screening, 27% of MP (95% CI 12% to 46%) make an intraoral examination as a routine. Interestingly, studies from each continent yielded significantly different outcomes to some research questions in the review. From the MP's perspective, clinical time restrictions and deficiencies in organised training were recognised as the main barriers towards their OC/OPC educational competence. The findings of this systematic review indicated the existence of deficiencies in knowledge and misconceptions, neglected preventive responsibilities, and associated barriers towards OC/OPC. A need for improved OC/OPC training at all levels of medical education is required to increase competence worldwide.

Oral epithelial dysplasia: Causes, quantification, prognosis, and management challenges

Oral epithelial dysplasia is a spectrum of architectural and cytological epithelial changes caused by accumulation of genetic changes, and is associated with an increased risk of progression to squamous cell carcinoma. It is a microscopic diagnosis of immense clinical importance. The initial reports of oral potentially malignant disorders with oral epithelial dysplasia transforming to oral cancer helped in understanding the nature of oral malignancies. Since then, clinical studies on oral potentially malignant disorders have combined microscopic findings of oral epithelial dysplasia to assess the malignant transformation potential of different grades of epithelial dysplasia. A significant amount of scientific literature has amassed on oral epithelial dysplasia relating to aspects of its diagnosis and management. However, the evidence base is weak as a result of the significant variability of published research. Poorly described study methods, variability in different oral epithelial dysplasia grading systems, inter- and intra-examiner variability causing issues of reliability, inadequate sample size, and inconsistent durations of follow-up are some of the methodological issues contributing to the failure to provide dependable information. Randomized clinical trials on the malignant transformation potential of oral epithelial dysplasia and its treatment outcomes are limited. This comprehensive literature review on oral epithelial dysplasia summarizes the scientific knowledge published in the scientific literature in English since its first description. The historical development, etiological factors, grading systems, diagnostic criteria, assessment of risk factors and prevention of malignant transformation, management principles of different grades of oral epithelial dysplasia (surgical and nonsurgical), recommendations on follow-up, and prognostic indicators are discussed in detail.

Association between p62 expression and clinicopathological characteristics in oral leukoplakia

Objective

Oral leukoplakia is keratinized lesions in the buccal mucosa, tongue, and gingiva. It is the most common oral precancerous lesion; oxidative stresses and irrelevant autophagy have been reported to be the cause of oncogenesis. p62, a cytoplasmic protein induced by oxidative stress, is an adaptor protein involved in the formation of protein aggregates and induction and inhibition of autophagy. The inhibition of autophagy induces p62 overexpression and promotes oncogenesis via the oncogenic signaling pathway. The aim of the present study was to elucidate the involvement of intracellular expression of p62 in oral leukoplakia and to address its potential clinical implementation as a biomarker to predict malignant transformation.

Material and Methods

Fifty samples from subjects with confirmed oral leukoplakia were evaluated by immunohistochemical staining for the expression of p62, 8-hydroxy-2'-deoxyguanosine (8-OHdG), Ki67, and p53. Univariate and multivariate logistic regression analyses were performed to evaluate the association between p62, 8-OHdG, Ki67, and p53 and clinical characteristics, including epithelial dysplasia.

Results

Significant associations were observed between p62 expression in the nucleus, p62 aggregation, and epithelial dysplasia (adjusted odds ratio [OR] = 5.75; 95% confidence interval [CI]: [1.28, 26.2]; .024 and OR = 6.16; 95% CI: [1.01, 37.4]; .048, respectively). The expression of p62 in the cytoplasm and the levels of 8-OHdG, Ki67, and p53 were not significantly associated with epithelial dysplasia. A significant relationship was found between p62 expression in the nucleus and p53 expression (OR = 3.94; 95% CI: [1.14, 13.6]; .031).

Conclusions

The results suggested that p62 expression in the nucleus and p62 aggregation can be potential markers to predict the malignant transformation of oral leukoplakia.

Oral potentially malignant disorders: risk of progression to malignancy

Oral potentially malignant disorders (OPMDs) have a statistically increased risk of progressing to cancer, but the risk varies according to a range of patient- or lesion-related factors. It is difficult to predict the risk of progression in any individual patient, and the clinician must make a judgment based on assessment of each case. The most commonly encountered OPMD is leukoplakia, but others, including lichen planus, oral submucous fibrosis, and erythroplakia, may also be seen. Factors associated with an increased risk of malignant transformation include sex; site and type of lesion; habits, such as smoking and alcohol consumption; and the presence of epithelial dysplasia on histologic examination. In this review, we attempt to identify important risk factors and present a simple algorithm that can be used as a guide for risk assessment at each stage of the clinical evaluation of a patient.

The premarket assessment of the cost-effectiveness of a predictive technology "Straticyte™" for the early detection of oral cancer: a decision analytic model

INTRODUCTION

Approximately half of oral cancers are detected in advanced stages. The current gold standard is histopathological assessment of biopsied tissue, which is subjective and dependent on expertise. Straticyte™, a novel prognostic tool at the pre-market stage, that more accurately identifies patients at high risk for oral cancer than histopathology alone. This study conducts an early cost-effectiveness analysis (CEA) of Straticyte™ and histopathology versus histopathology alone for oral cancer diagnosis in adult patients.

METHODS

A decision-analytic model was constructed after narrowing the scope of Straticyte™, and defining application paths. Data was gathered using the belief elicitation method, and systematic review and meta-analysis. The early CEA was conducted from private-payer and patient perspectives, capturing both direct and indirect costs over a five-year time horizon. One-way and probabilistic sensitivity analyses were conducted to investigate uncertainty.

RESULTS

Compared to histopathology alone, histopathology with Straticyte™ was the dominant strategy, resulting in fewer cancer cases (31 versus 36 per 100 patients) and lower total costs per cancer case avoided (3,360 versus 3,553). This remained robust when Straticyte™ was applied to moderate and mild cases, but became slightly more expensive but still more effective than histopathology alone when Straticyte™ was applied to only mild cases. The probabilistic and one-way sensitivity analyses demonstrated that incorporating Straticyte™ to the current algorithm would be cost-effective over a wide range of parameters and willingness-to-pay values.

CONCLUSION

This study demonstrates high probability that Straticyte™ and histopathology will be cost-effective, which encourages continued investment in the product. The analysis is informed by limited clinical data on Straticyte™, however as more data becomes available, more precise estimates will be generated.

Inter- and intra-observer variability in three grading systems for oral epithelial dysplasia

Background and Objectives:

Management of oral premalignant lesions depends on clinical assessment and grading of oral epithelial dysplasia (OED), which remains one of the most important predictors of malignant potential. Numerous grading systems for OED exists with varying sets of assessing criteria and are largely considered subjective. The present study attempted to assess the inter- and intra-observer variability in three grading systems: Binary system, WHO (2005) and Ljubljana systems.

Methodology:

Histopathological grading of 63 cases of leukoplakia was performed by two oral pathologists and one general pathologist, who were blinded, using all the three grading systems at different time intervals and was repeated twice. Inter- and intra-observer variability was then evaluated by multivariate kappa analysis.

Results:

Inter-observer agreement in the two set of observations was found to be “slight” in WHO (k = 0.001 and 0.039), “slight” and “poor” in binary (k = 0.108 and −0.007), “poor” and “slight” in Ljubljana's (k = −0.027 and 0.106) grading systems. Intra-observer agreement ranged from “slight” to “fair” (k = 0.128 and 0.295) in WHO, “fair” to “moderate” (k = 0.224 and 0.420) in binary and “slight” to “fair” (k = 0.161 and −0.353) in Ljubljana's grading systems.

Conclusions:

The binary system of classification proved to have an overall better inter- and intra-observer agreement. This study also showed better intra-observer agreement in all the grading systems as well as in individual histopathological parameters. Defining the individual parameters more objectively with the reproducible structuring of the grading systems and training of the pathologists would help reduce the variability in diagnosing dysplasia.

Should severe epithelial dysplasia be treated?

OBJECTIVE

To identify clinical features associated with progression of primary severe epithelial dysplasia into invasive squamous cell carcinoma (SCC).

DESIGN

Longitudinal population-based study.

SETTING

Oral dysplasia clinics.

PATIENTS

This study involved 118 patients with 118 severe dysplasia who were prospectively enrolled between 1996 and 2014, and the lesions were either completely removed surgically (treated) or actively followed (untreated).

MEASUREMENTS

Demographics, habits, clinical information and outcome were compared between the treated and untreated groups.

RESULTS

Of the 118 lesions, 77 were treated and 41 were not. The treated lesions showed significantly less progression when compared to the untreated: 5/77 (6%) treated lesions progressed into invasive SCC versus 12/41 (29%) untreated (P=0.004). The 5-year probability (confidence interval) of progression into SCC for the treated was 7.6 (1-14) as compared to 38.6 (16-55) for the untreated. Interestingly the clinical changes at the site of the disease also had strong predictive value for cancer progression. If the site showed no lesion after treatment or after incisional biopsy (40 cases), only 1 (3%) progressed into cancer. If the site showed ever disappearance of the lesion or marked decrease in the size of the lesion to ⩽10mm (29 cases), 4 (15%) progressed. If the site showed lesions with fluctuation in size or persistent in size or marked increase in size (25 cases), 18 (58%) progressed (P<0.001).

CONCLUSION

Treatment significantly reduced cancer progression, and phenotypic changes at the site of the disease had significant predictive value for cancer progression.

Meta-analysis on clinicopathologic risk factors of leukoplakias undergoing malignant transformation

Context:

Leukoplakia is classified under the term potentially malignant disorder. This term does not suggest the clinician or the patient about the severity of the disease to undergo a malignant transformation. Thus, there arises a need to identify the risk factors associated with malignant transformation (MT) to predict it at the earliest.

Aims:

To generate evidence regarding the clinicopathologic factors affecting MT in oral leukoplakias.

Materials and Methods:

Meta-analysis was done by extracting data from all the previous studies published. Articles were searched in PubMed databases.

Statistical Analysis:

Mixed model by using the PROC MIXED (SAS 9.3) was performed to estimate the effect of different factors such as gender, type of habit (smoking tobacco, gutka, paan (with tobacco) and no habit association), clinical type and histopathology on MT. The lower specific mean for MT was also calculated with respect to the above-mentioned factors.

Results:

Speckled leukoplakias also known as erythroleukoplakia confirmed to be at the highest risk. Lateral border of the tongue followed by gingiva, buccal mucosa, floor of the mouth, lesions involving tongue and floor of mouth showed increased risk. Smoking tobacco (cigarette and bidi) and idiopathic leukoplakia (without habit) carried almost equal risk. Gender had minimal influence on MT. Histopathologic correlation of grades showed an insignificant bearing on MT.

Conclusion:

The carcinogenic transformation of a preexisting lesion (leukoplakia) is multifactorial and patient specific. The protocol to delineate a high-risk lesion should include the clinical type and site.

Lugol's iodine identifies dysplastic tissue in precancerous lesions: A clinical trial

Introduction:

Intraepithelial dysplasia, or “invisible” precancerous lesions, provides a challenge for visualization to the surgical team. The prognostic relevance of dysplasia and carcinoma in situ at surgical margins is well documented.

Materials and Methods:

We evaluated the use of Lugol's iodine in visualizing the surgical margins of dysplastic tissue by an observational study of 100 patients having oral precancerous lesions between June 2013 and March 2016.

Conclusion:

Lugol's iodine is a simple, inexpensive, and apparently effective means of diagnosing and visualizing the surgical margins of the dysplastic tissue in oral precancerous lesions.

Malignant Transformation Rate in Patients Presenting Oral Epithelial Dysplasia: Systematic Review and Meta-Analysis

Objective. To perform a systematic review and meta-analysis on studies that assess malignant transformation rates (MTR) of oral epithelial dysplasia. Materials and Methods. This review was planned and conducted in accordance with the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. PubMed, EMBASE, Google Scholar, and Cochrane databases were screened to identify observational studies. Quality assessments were completed by two reviewers independently using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Pooled-malignant transformation rate (MTR) in person years, subgroup, sensitivity, and publication bias analysis were calculated using STATA 13.0 and Comprehensive Meta-Analysis software. Results. Sixteen observational cohort studies were identified with a total of 3708 participants from Asia, North America, and Europe. Analysis showed a MTR of 10.5% (pooled-MTR: 10.5, 95% CI: 3.7 to 17.3; fixed effect model, I2=0.0%; Q-value = 2.389; p>0.05) among patients with histologically confirmed oral epithelia dysplasia undergoing long-term follow-up. Higher MTR in person year were seen among the sever dysplastic cases (pooled-MTR: 14.4%, 95% CI: 5.3% to 23.5%), studies published in Europe (pooled-MTR: 12.6%, 95% CI: 8.0% to 24.3%), and retrospective studies (pooled-MTR: 11.0%, 95% CI: 2.2% to 19.9%). Conclusion. These studies show that oral epithelial dysplasia has a significant high rate of transformation to cancer.

Prevalence of fungal hyphae in potentially malignant lesions and conditions-does its occurrence play a role in epithelial dysplasia?

BACKGROUND

Oral cancer is a major public health problem in India. A key factor that has led to lack of improvement in prognosis of oral cancer over the years, is delay in diagnosis and treatment. In many instances, a significant proportion of oral squamous cell carcinomas develop from premalignant lesions and conditions. Identification of such lesions and conditions is very important in order to prevent malignant transformation. The role of fungal infections has been studied and holds promise as an indicator to predict malignant transformation. So we designed a study to analyze the prevalence of fungal hyphae in biopsies of patients with clinically diagnosed cases of premalignant lesions and conditions.

AIMS AND OBJECTIVES

To determine and compare the prevalence of fungal hyphae in biopsies of patients with clinically diagnosed cases of potentially malignant lesions and conditions and to assess the possible association between the degree of epithelial dysplasia and presence or absence of fungal hyphae.

MATERIALS AND METHODS

Clinically suspected and histopathologically diagnosed 70 cases of potentially malignant lesions and conditions (29 leukoplakia, 16 submucous fibrosis and 25 lichen planus) made up the study group. Three tissue sections (5μm) of each were stained with hematoxylin and eosin (H and E), periodic acid-Schiff's reagent (PAS) and Grocott's methenamine silver (GMS) and evaluated for fungal hyphae. The data collected was statistically analyzed by using Chi-square test and Statistical Package for Social Sciences (SPSS) software.

RESULTS

The estimated prevalence of fungal hyphae in cases with or without dysplasia in leukoplakia was 41.4%, lichen planus 36% and submucous fibrosis 25%. There was a significant association between degree of epithelial dysplasia with presence or absence of fungal hyphae in all the study groups.

CONCLUSION

Presence of fungal hyphae in potentially malignant lesions and conditions may prove to be a useful indicator in predicting malignant transformation.

Oral lichen planus: study of 21 cases

BACKGROUND:

Lichen planus is considered to be the most common dermatological disease involving the oral mucosa.

OBJECTIVE:

To investigate the profile, clinical features, and the presence of dysplasia and candidiasis in patients with oral lichen planus.

METHODS:

A total of 21 patients were selected from 258 patients at risk for oral cancer development.

RESULTS:

Most of the patients were white (76,2%), female (66,6%), with mean age of 58.8 years. Eight were smokers and seven were alcohol consumers. The buccal mucosa was the most affected site, followed by the tongue and the gingiva. The reticular pattern was the most common appearance. Histopathology depicted dysplasia in nine cases and cytopathology was positive for Candida in eight cases in the first appointment.

CONCLUSION:

Our data are similar to the literature. Cytopathology was important for the diagnosis of candidiasis. Although the presence of dysplasia was verified, further studies are necessary to clarify the importance of this finding.

Oral leukoplakia - is biopsy at the initial appointment a must?

BACKGROUND

Oral leukoplakia is a potentially malignant disorder of the oral cavity. Leukoplakias with chances of undergoing malignant transformation owing to the presence of dysplastic changes may not be clinically distinguishable from leukoplakias without dysplasia. The study was carried out to evaluate the usefulness of biopsy in assessing the clinico-pathologic correlations of oral leukoplakia at the patient's initial visit.

MATERIALS AND METHODS

Hospital records with clinical diagnosis of oral leukoplakia were retrospectively analysed. All these patients had undergone biopsy in their initial visit. Histopathological slides were reviewed and reported by a single pathologist. Diagnosis agreement was considered to be present if the clinical diagnosis matched the histopathological diagnosis. Misdiagnosis was considered if the clinical diagnosis did not match the histopathological diagnosis and underdiagnosis when malignancy was detected on histopathological examination.

RESULTS

A total of 115 patients were clinically diagnosed with oral leukoplakia. According to clinical appearance of the leukoplakia patch was categorized in to three types viz homogeneous leukoplakia (n= 24 i.e. 20.87%), speckled leukoplakia (n=76 i.e. 66.08%) and verrucous leukoplakia (n=15 i.e. 13.04%). Histopathological examination confirmed clinical diagnosis in 88 cases (a diagnosis agreement of 76.52%). Histopathological examination of 19 cases revealed a different diagnosis, thus categorized as misdiagnosis (16.52%) and 8 cases had unexpected malignancy which accounted for underdiagnosis in 6.96% cases. There was dysplasia in 45 (51.13%) of the histopathologically confirmed cases of leukoplakia.

CONCLUSION

The clinical appearance of suspicious white lesions does not provide a true nature of its disease status and malignant changes may be missed.

PITX1 is a reliable biomarker for predicting prognosis in patients with oral epithelial dysplasia

Paired-like homeodomain 1 (PITX1) genes are essential in human development. In the present study, PITX1 protein expression was evaluated in human normal oral mucosa, oral epithelial dysplasia and oral squamous cell carcinoma (OSCC), with the aim of examining the expression patterns of these critical genes during the multi-stage transformation of oral epithelial dysplasia to OSCC. PITX1 and Ki-67 expression were assessed by immunohistochemistry in 26 individuals with normal oral mucosa, 106 patients with oral epithelial dysplasia and 97 OSCC patients. The labeling indices (LIs) of PITX1 and Ki-67 were calculated and their correlation with the incidence of malignancy was evaluated. The PITX1 LI of the dysplasia specimens was significantly lower than that of the normal oral mucosa samples, but significantly higher than that of the OSCC samples. The oral epithelial dysplasia patients that exhibited low PITX1 expression showed a significantly higher incidence of malignant transformation than those exhibiting high PITX1 expression, regardless of the histological grades of their oral epithelial dysplasias. On the other hand, no correlation was observed between the Ki-67 LI and the incidence of malignancy. These results suggested that PITX1 suppression is associated with malignant transformation in the oral epithelium and that PITX1 expression may serve as a novel biomarker for predicting prognosis in oral epithelial dysplasia.

Prognostic significance of p53 immunoexpression in the survival of oral squamous cell carcinoma patients treated with surgery and neoadjuvant chemotherapy

p53 status is a key biomarker for a variety of cancer types. However, it remains controversial whether p53 is an effective biomarker in oral squamous cell carcinoma (OSCC), particularly with regard to its prognostic value for OSCC patients with combinational treatment. The aim of the current study was to evaluate the prognostic potential of p53 immunoexpression in samples from OSCC patients treated with surgery only or surgery and neoadjuvant chemotherapy. p53 expression was assessed immunohistochemically in biopsy tissues from 44 OSCC patients with a mean follow-up of 35.6 months. Correlations between p53 status, tumor size (T-classification), lymph node status (N-classification) and clinical outcome were analyzed. It was observed that p53-positive and N0 cases correlated with higher 5-year survival rates in cases treated with surgery alone (P=0.017 and P=0.03, respectively), while in cases with neoadjuvant chemotherapy, p53 status and lymph node status did not exhibit prognostic significance. Tumor size showed no prognostic value in cases receiving surgery alone or in those with neoadjuvant chemotherapy. The present results demonstrated for the first time that p53 immunohistochemical expression correlates with a good prognosis in OSCC patients receiving surgery alone. In conclusion, p53 immunohistochemical expression and lymph node status may serve as prognostic markers for the survival of OSCC patients receiving surgery only, but not for patients undergoing surgery and neoadjuvant chemotherapy treatment.

Stem cell niche structure as an inherent cause of undulating epithelial morphologies

The spatial organization of stem cells into a niche is a key factor for growth and continual tissue renewal during development, sustenance, and regeneration. Stratified epithelia serve as a great context to study the spatial aspects of the stem cell niche and cell lineages by organizing into layers of different cell types. Several types of stratified epithelia develop morphologies with advantageous, protruding structures where stem cells reside, such as rete pegs and palisades of Vogt. Here, multistage, spatial cell lineage models for epithelial stratification are used to study how the stem cell niche influences epithelial morphologies. When the stem cell niche forms along a rigid basal lamina, relatively regular morphologies are maintained. In contrast, stem cell niche formation along a free-moving basal lamina may prompt distorted epithelial morphologies with stem cells accumulating at the tips of fingerlike structures that form. The correspondence between our simulated morphologies and developmental stages of the human epidermis is also explored. Overall, our work provides an understanding of how stratified epithelia may attain distorted morphologies and sheds light on the importance of the spatial aspects of the stem cell niche.

An Insight to Oral Epithelial Dysplasia

Oral dysplasia is a potentially precancerous lesion diagnosed histologically. While the risk of progression is associated with histological grade, it is currently impossible to predict accurately which lesions will progress. Although most oral pathologists recognize and accept the criteria for grading epithelial dysplasia based on architectural and cytological changes, there can be considerable interexaminer and intraexaminer variation in the assessment of the presence or absence and the grade of oral epithelial dysplasia. This article reviews the alterations, criteria, different grading systems and the markers used for assessing the malignant transformation of epithelial dysplasia.

How to cite this article

Rastogi V, Puri N, Mishra S, Arora S, Kaur G, Yadav L. An Insight to Oral Epithelial Dysplasia. Int J Head Neck Surg 2013;4(2):74-82.

The expression of E-cadherin and cathepsin-D in normal oral mucosa, oral epithelial dysplasia and oral squamous cell carcinoma: A comparative analysis between immunohistochemistry and routine histopathology

Background:

E-cadherin is known to be an invasion suppressor gene and cathepsin-D, a protease, which is an invasion promoter and plays a central role in solid tumors including oral cancer.

Aims:

To look for the expression pattern in normal buccal mucosa, dysplastic oral epithelium and oral squamous cell carcinoma (SCC) along with their correlation to individual atypical features, thereby providing an objective to the grading system in predicting the fate of affected epithelium.

Materials and Methods:

To elucidate the expression patterns of these markers, we examined immunohistochemically on formalin fixed, paraffin embedded sections 22 dysplastic epithelia, eight SCC and ten normal buccal mucosa.

Results:

In dysplastic epithelium slight loss of expression of E-cadherin was noted as grade of dysplasia increased. Two cases of carcinoma clearance showed only basal and suprabasal staining. The staining varied in SCC with patchy to complete absence of expression. With cathepsin-D fine to moderate granular cytoplasmic staining was noted in most of the dysplastic epithelium. Similar staining was noted in SCC. The atypical features which strongly correlated to loss of expression of E-cadherin and intense cathepsin-D expression are basilar hyperplasia, loss of cohesion, mitosis, loss of polarity and drop shaped rete ridges.

Conclusions:

The result of the study shows that the above atypical features should be given more weightage in addition to traditional grading system, in predicting the fate of affected epithelium. Additional studies with larger sample size and using monoclonal antibody against cathepsin-D may further strengthen our findings.

The prevalence of actinic cheilitis in farmers in a semi-arid northeastern region of Brazil

BACKGROUND

Actinic cheilitis (AC) is a potentially malignant disorder of the lip caused by chronic exposure to solar radiation. Despite being a relatively common lesion in tropical countries, the data related to AC prevalence in Brazil are sparse, particularly in regions with high levels of ultraviolet radiation.

OBJECTIVE

To estimate AC prevalence among farmers in a semiarid northeastern Brazil.

METHODS

Cross-sectional study was carried out involving a representative sample (n = 240) of the farm workers. Sociodemographic, clinical, and histopathological variables were analyzed.

RESULTS

AC prevalence was 16.7% [95% confidence interval (CI): 12.0% to 21.4%]. The disease was more prevalent in males [prevalence ratio (PR) = 2.72; 95% CI: 1.52-4.90], fair-skinned farmers (PR = 2.07; 95% CI: 1.00-4.30), age over 50 years (PR = 2.91; 95% CI: 1.40-6.04), daily exposure time more than eight hours (PR = 1.84; 95% CI: 1.03-3.27), and among smokers/ex-smokers (PR = 2.17; 95% CI: 1.22-3.87). Mantel-Haenszel test showed a positive relationship between cumulative exposure time and development of AC (P < 0.001). Two cases were diagnosed as microinvasive squamous cell carcinoma.

CONCLUSIONS

Our results suggest that farmers in this semiarid area have a high risk of lip cancer and indicate the need for health public programs in the early detection of AC and education to teach the population about precautions to be taken during sun exposure.

Salivary IL-6 levels in oral leukoplakia with dysplasia and its clinical relevance to tobacco habits and periodontitis

The development of oral cancer proceeds through discrete molecular changes that are acquired from loss of genomic integrity after continued exposure to environmental risk factors. It is preceded in the majority of cases by clinically evident oral potentially malignant disorders, the most common of which is leukoplakia. Early detection of these oral lesions by screening methods using suitable markers is critical as it mirrors molecular alterations, long before cancer phenotypes are manifested. Assessment of salivary interleukin-6 (IL-6) as a marker of malignant progression was undertaken in patients with leukoplakia having coexisting periodontitis (n = 20), periodontitis patients without leukoplakia (n = 20), and healthy controls (n = 20) by competitive enzyme-linked immunosorbent assay. Results showed elevation of IL-6 levels in leukoplakia with coexisting periodontitis and in periodontitis patients when compared to healthy control (P < 0.001). Within the leukoplakia group, IL-6 level was found to be increased with increase in the severity of dysplasia. The use of tobacco was seen to play a significant role in the elevation of salivary IL-6.The importance of IL-6 as a specific marker for leukoplakia with dysplasia and the role of tobacco as an independent risk factor has been highlighted.

Grading oral epithelial dysplasia: analysis of individual features

BACKGROUND

Assessing epithelial dysplasia to predict malignant transformation remains problematic in many tissues because grading systems are poorly structured and individual features poorly defined. Dysplasia grading is criticised for lack of reproducibility and poor predictive value. Grading systems for upper aerodigestive tract dysplasia have evolved over several decades and are not supported by good outcome experimental data.

METHODS

 This study analysed the individual features of dysplasia in 86 oral dysplastic lesions and determined the reproducibility of scoring for each, and correlated them with other features and clinical factors using complex clustering analyses.

RESULTS

A uniform pattern of dysplasia was found in 37 lesions, focal dysplasia in 36 and in 13 lesions dysplasia formed complex discontinuous patterns. There was wide variation in reproducibility of scoring of individual features and many, including thickness, some types of rete morphology, basaloid cell anisonucleosis, basal dyscohesion, and dyskeratosis as deep single cells correlated with sub-sites. Rete morphology, type of keratinisation, hyperchromatism of the basaloid compartment, prickle cell anisonucleosis and extension down salivary ducts correlated with smoking. Conventional grading and oral intraepithelial neoplasia (OIN) grading by 'thirds affected' showed strong correlation overall but scores obtained with the OIN system tended to a higher grade at all sites except soft palate/fauces. There was poor correlation between the systems for moderate dysplasia and also severe dysplasia at some sites. Individual features could not be shown to cluster to form distinct patterns of dysplasia.

CONCLUSIONS

These variations may account in part for the lack of reproducibility and poor predictive value of the grading systems in current use and could inform the design of future grading systems.

Relevance of tumor angiogenesis patterns as a diagnostic value and prognostic indicator in oral precancer and cancer

Tumor angiogenesis occurs by recruitment of endothelial cell precursors or by sprouting of existing capillaries, which differ from the normal vasculature by having an altered morphology that can be exploited for diagnosis and as a prognostic indicator. Improved technologies have propelled diagnosis into a new era. These technologies have to be used with great precision. The diagnosis of a dysplastic premalignant lesion of the oral mucosa cannot be based solely on clinical findings. Therefore histologic evaluation of a representative biopsy specimen is necessary. Accurate judgment of the proper site for biopsy is essential for reaching a correct diagnosis. The aim of this report is to analyze the vascular patterns with the help of direct oral microscopy and the technique of stereo-optical microscopy in the oral cavity to select biopsy sites, and compare the outcome of a directed biopsy with that of biopsy specimens obtained from sites selected solely on the basis of clinical criteria. The study sample comprised 50 oral mucosal lesions. A statistically significant difference was noted between samples judged to be microscopically representative sites. We conclude that this method would aid in early and better diagnosis and treatment planning of oral premalignant and malignant lesions by assessing the various vascular patterns in the mucosa.

Oral premalignant lesions: from a clinical perspective

In this review article, the clinical and histopathological characteristics of oral premalignant lesions, and primarily oral leukoplakia, are noted and the risk factors for malignant transformation of oral leukoplakia are discussed. Malignant transformation rates of oral leukoplakia range from 0.13 to 17.5%. The risk factors of malignant transformation in the buccal mucosa and labial commissure are male gender with chewing tobacco or smoking in some countries such as India, or older age and/or being a non-smoking female in other countries. Some authors have reported that leukoplakia on the tongue or the floor of the mouth showed a high risk of malignant transformation, although others have found no oral subsites at high risk. In concurrence with some authors, the authors of this review view epithelial dysplasia as an important risk factor in malignant transformation; however, there are conflicting reports in the literature. Many authors believe that nonhomogeneous leukoplakia is a high risk factor without exception, although different terms have been used to describe those conditions. The large size of lesions and widespread leukoplakia are also reported risk factors. According to some studies, surgical treatment decreased the rate of malignant transformation; however, many review articles state that no definitive treatment including surgery can decrease the malignant transformation rate of oral leukoplakia because of the lack of randomized control trials of treatment. Tobacco chewing and smoking may be causative agents for cancerization of oral leukoplakia in some groups, and evidence for a role of human papilloma virus in the malignant transformation of oral leukoplakia is inconsistent. Further research to clarify its role in malignant transformation is warranted.

Two members of the SIBLING family of proteins, DSPP and BSP, may predict the transition of oral epithelial dysplasia to oral squamous cell carcinoma

BACKGROUND

: Patients with oral premalignant lesions (OPL) present with oral squamous cell carcinomas (OSCC) at a much higher rate than the general population. There are currently no useful markers that indicate specifically which OPLs are most likely to progress. Three small integrin binding ligands N-linked glycoprotein (SIBLING) family proteins, bone sialoprotein (BSP), osteopontin (OPN), and dentin sialophosphoprotein (DSPP), have been shown to be up-regulated in many cancers, including OSCC. The status of SIBLING expression in OPLs and their correlation to transition to oral cancer are unknown.

METHODS

: Sixty archival surgical biopsies of dysplastic OPLs were evaluated by immunohistochemistry for expression of BSP, DSPP, and OPN and correlated with local transformation to OSCC at sites adjacent to surgically removed dysplastic OPL.

RESULTS

: The OPL patient population was representative of previous studies with 20% progressing to OSCC, and no correlation between degree of dysplasia and progression. Eighty-seven percent were positive for at least 1 SIBLING protein. OPN expression had no correlation with progression. The BSP+/DSPP- expression pattern however correlated with decreased transformation to OSCC (point prevalence = 0%; 95% confidence interval [CI], 0-20.6), whereas the BSP-/DSPP+ pattern was associated with more frequent progression (point prevalence = 77.8%; 95%CI, 47.8-95.4). Incrementally higher expression scores (0 to 3) of BSP and DSPP were also associated with increased predictive values (odds ratio, 25.53; 95% CI, 2.14-304.7 and 10.13; 95% CI, 2.0-50.0, respectively, for each increment).

CONCLUSIONS

: BSP and DSPP are excellent candidate markers for successful OPL surgical intervention and may be predictors of OPL-OSCC progression. Cancer 2010. (c) 2010 American Cancer Society.

Expression of cytokeratins 10, 13, 14 and 19 in oral lichen planus

OLP is a chronic inflammatory disease of unknown etiology that may develop into squamous-cell carcinoma. Cytokeratins, which are important components of the cytoskeleton, are excellent epithelial differentiation markers used to study neoplastic and inflammatory diseases. To study the profile of cytokeratins in OLP and their possible association with dysplastic alterations, monoclonal antibodies were used for cytokeratins 10, 13, 14 and 19, in 26 samples of OLP. The streptavidin-biotin technique was employed in paraffin-embedded tissue sections. Sample analysis revealed suprabasal expression of cytokeratin 10 in 16/17 samples, 14 of them with reduced expression; suprabasal expression of cytokeratin 13 in 18/23, 16 of them with delay; basal and suprabasal expression of cytokeratin 14 in all samples; and focal basal expression of cytokeratin 19 in 4/21. Expression of cytokeratins 10, 13 and 14 was altered in OLP lesions. The inflammatory process and hyperkeratosis or parakeratosis seem to have interfered with the expression of these CKs. Cytokeratin 19 was expressed in the lesions, in a pattern similar to that mentioned in the literature for the non-keratinized oral mucosa. The presence of mild dysplasia did not change the expression of the cytokeratins studied. No differences in pattern of expression were observed between keratinized and non-keratinized areas in the lesions caused by OLP.

Oral lichen planus versus epithelial dysplasia: difficulties in diagnosis

Histopathological diagnosis of oral lichen planus is not easy since some cases of epithelial dysplasia may present traits which are very similar to those from lichen planus.

Aim

to compare cell alterations which suggest malignancy present in oral lichen planus with those from epithelial dysplasia.

Material and methods

histological cross-sections of oral lichen planus and dysplasia, dyed by hematoxylin-eosin, were analyzed by means of light microscopy.

Results

variance analysis (alpha=5%) revealed a statistically significant difference between the average number of cell alterations in the lichen planus (5.83±1.61) and epithelial dysplasia (4.46±1.26). The chi-squared test did not show statistically significant differences between oral lichen planus and epithelial dysplasia in relation to the following cell alterations: increase in nucleus/cytoplasm ratio, nuclear hyperchromatism, irregular chromatin distribution and enlarged nuclei (p>0.05).

Conclusion

Some cell alterations which suggest malignancy present in the oral lichen planus may also be found in epithelial dysplasia, impairing its diagnosis and, consequently, stressing the importance of following these patients in the long run.

p53 and MDM2 protein expression in actinic cheilitis

Actinic cheilitis is a potentially malignant lip lesion caused by excessive and prolonged exposure to ultraviolet radiation, which can lead to histomorphological alterations indicative of abnormal cell differentiation. In this pathology, varying degrees of epithelial dysplasia may be found. There are few published studies regarding the p53 and MDM2 proteins in actinic cheilitis. Fifty-eight cases diagnosed with actinic cheilitis were histologically evaluated using Banóczy and Csiba (1976) parameters, and were subjected to immunohistochemical analysis using the streptavidin-biotin method in order to assess p53 and MDM2 protein expression. All studied cases expressed p53 proteins in basal and suprabasal layers. In the basal layer, the nuclei testing positive for p53 were stained intensely, while in the suprabasal layer, cells with slightly stained nuclei were predominant. All cases also tested positive for the MDM2 protein, but with varying degrees of nuclear expression and a predominance of slightly stained cells. A statistically significant correlation between the percentage of p53 and MDM2-positive cells was established, regardless of the degree of epithelial dysplasia. The expression of p53 and MDM2 proteins in actinic cheilitis can be an important indicator in lip carcinogenesis, regardless of the degree of epithelial dysplasia.

Oral Erythroplakia and Speckled Leukoplakia: retrospective analysis of 13 cases

Erythroplakia and speckled leukoplakia are oral precancerous lesions that have a high potential for malignant transformation.

Aim

A retrospective analysis was conducted to investigate the clinicopathologic features of 13 cases of oral erythroplakia and speckled leukoplakia in patients who were seen at a center specialized in stomatology and Histopathological diagnosis of oral diseases.

Materials and Methods

All cases diagnosed with erythroplakia and speckled leukoplakia between 1978 and 2006 were retrieved from the service archives.

Results

The lesions exhibited a predilection for males with a female-to-male ratio of 1:3.3. Mean age was 57 years old and soft palate was the site affected in 77% of the cases. Pain symptoms were reported by 61.5% of the patients and association with risk factors such as smoking and excessive alcohol intake was seen in 100% and in 46% of the cases, respectively. The lesions showed epithelial dysplasia, where more than 50% were diagnosed as in situ or invasive carcinoma.

Conclusions

Despite low prevalence, oral homogeneous erythroplakia and speckled leukoplakia show Histopathological alterations vary from epithelial dysplasia to invasive carcinoma. These lesions must be included among those oral lesions with the highest potential for malignant tranformation.