Advanced diagnostic methods in oral and maxillofacial pathology. Part II: immunohistochemical and immunofluorescent methods

Immunohistochemistry Biomarkers-Guided Image Search for Histopathology

Medical practitioners use a number of diagnostic tests to make a reliable diagnosis. Traditionally, Haematoxylin and Eosin (H&E) stained glass slides have been used for cancer diagnosis and tumor detection. However, recently a variety of immunohistochemistry (IHC) stained slides can be requested by pathologists to examine and confirm diagnoses for determining the subtype of a tumor when this is difficult using H&E slides only. Deep learning (DL) has received a lot of interest recently for image search engines to extract features from tissue regions, which may or may not be the target region for diagnosis. This approach generally fails to capture high-level patterns corresponding to the malignant or abnormal content of histopathology images. In this work, we are proposing a targeted image search approach, inspired by the pathologists' workflow, which may use information from multiple IHC biomarker images when available. These IHC images could be aligned, filtered, and merged together to generate a composite biomarker image (CBI) that could eventually be used to generate an attention map to guide the search engine for localized search. In our experiments, we observed that an IHC-guided image search engine can retrieve relevant data more accurately than a conventional (i.e., H&E-only) search engine without IHC guidance. Moreover, such engines are also able to accurately conclude the subtypes through majority votes.

Role of Advanced Diagnostic Aids in the Detection of Potentially Malignant Disorders and Oral Cancer at an Early Stage

One of the most prevalent malignancies diagnosed today is cancer of the mouth or oral cancer. Compared to systemic malignancies like lung cancer, colon cancer, etc., oral cancer tends to get less attention from the general public. However, these lesions may be lethal if not treated, even if diagnosed early. Early diagnosis improves the prognosis for successful therapy. Delayed diagnosis is hypothesized to be a pivotal contributor to the dismal oral cancer survival rate over five years. The current standard of care for diagnosis and detection is based on clinical evaluation, the histological study of biopsy material, and genetic methods. There have been several advancements in the diagnostic technologies available to detect oral cancer at the initial phase. This study aims to dissect the cutting-edge methods for detecting oral cancer in its earliest stages.

Myofibroblasts and increased angiogenesis contribute to periapical cystic injury containment and repair

Background

Myofibroblasts (MF) and angiogenesis are important factors in the development and expansion of cystic lesions, where these cells secrete growth factors and proteases, stimulating angiogenesis, matrix deposition and cell migration, affecting the growth of these periapicopathies. The present study aimed to evaluate the immunohistochemical expression of CD34 and α-SMA in radicular cysts (RC) and residual radicular cysts (RRC), with the purpose of contributing to a better understanding of the expansion and progression of these periapical lesions.

Material and Methods

The present study os a descriptive, quantitative and comparative analysis of positive CD34 and α-SMA immunohistochemical expressions in 30 RC and 30 RRC specimens. α-SMA expression was evaluated in the fibrous capsule of the lesions, at 100x magnification below the epithelial lining. A total of 10 higher immunostaining fields were selected and subsequently, positive cells were quantified at 400x magnification, averaged per field. Regarding the angiogenic index, immuno-labeled microvessel counts for the anti-CD34 antibody were performed in 10 fields at 200x magnification.

Results

Statistically significant differences regarding α-SMA immunostaining were observed (p = 0.035), as well as a correlation between α-SMA versus CD34 (p = 0.004) in RRC. However, the angiogenic index obtained by immunostaining for CD34 indicated no statistical difference between lesions. Intense inflammatory infiltrates were predominant in RC, while mild and moderate degrees were more commonly observed in RRC (p <0.001). Intense inflammatory infiltrates were also more often noted in larger RRC (p = 0.041). Inflammatory infiltrates showed no significant correlation with α-SMA and CD34 immunostaining.

Conclusions

The results indicate that the significant correlation found between the presence of MF and the angiogenic index are related to the repair process in RRC.

Key words:Myofibroblasts, angiogenesis, inflammatory odontogenic cysts.

Clinical presentation and diagnostic delay in pemphigus vulgaris: A prospective study from Turkey

BACKGROUND

To evaluate the diagnostic patterns and factors that may influence delays in the diagnosis of pemphigus vulgaris (PV) with oral involvement.

MATERIALS AND METHODS

In this prospective cohort study, 36 newly diagnosed PV patients with oral involvement were clinically examined and interviewed about the natural history of the oral lesions, number of medical consultations (Med consultation), medical treatment history, and diagnostic delay time (DD time).

RESULTS

Thirty (83%) PV patients presented initially with oral mucosal involvement (OMI) and 6 (17%) presented initially with skin involvement (SI). The mean DD time was 6.19 ± 3.82 months, and the mean number of Med consultation was 5.8 (n = 36). The means of all the parameters were significantly higher for the OMI patients than for the SI patients (P < .05). All of the patients with OMI had been misdiagnosed. The DD time was significantly longer in patients who presented initially with desquamative gingivitis (8.25 ± 3.81) than patients who presented with ulcers and erosions (4.78 ± 1.11) (P < .05). There was a statistically significant positive correlation between DD time and Med consultation (r = 0.91).

CONCLUSION

Even with the high frequency of oral involvement and easy access to the oral cavity, diagnostic delays are still common for patients with oral PV. This underlines the need for education to improve healthcare providers' awareness and knowledge of the clinical oral presentation of PV.

The optimal oral biopsy site for diagnosis of mucous membrane pemphigoid and pemphigus vulgaris

BACKGROUND

Accepted 'standard practice' for the diagnosis of immunobullous disease is a perilesional sample for direct immunofluorescence (DIF).

OBJECTIVES

To compare diagnostic outcomes of a normal buccal punch biopsy (NBPB) with a perilesional biopsy (PLB) for mucous membrane pemphigoid (MMP) and pemphigus vulgaris (PV).

METHODS

A retrospective analysis of 251 DIF-positive patients with MMP and 77 DIF-positive patients with PV was undertaken. Parameters analysed included the intraoral sites of involvement and histopathological, DIF and indirect immunofluorescence (IIF) findings.

RESULTS

For MMP, PLB was positive in 134 of 143 (93·7%) samples, compared with 129 of 144 (89·6%) by NBPB. The diagnostic sensitivities for PLB (81%, 39 of 48) and NBPB (77%, 37 of 48) among 48 patients who underwent both techniques were not significantly different (P = 0·62). In gingival-only MMP, PLB was positive in 63 of 69 (91%) and NBPB was positive in 63 of 75 (84%). For multisite MMP, PLB was positive in 71 of 74 (96%) and NBPB was positive in 66 of 69 (96%). In gingival-only MMP, biopsies from reflected alveolar mucosa in 17 consecutive patients were positive in 17 of 17 cases (100%). For PV, PLB was positive in 42 of 43 (98%), compared with 42 of 42 (100%) by NBPB. Histopathology was diagnostic in 93 of 134 (69·4%) cases of MMP and 38 of 41 (93%) cases of PV. IIF was positive in 126 of 197 (64·0%) MMP and 68 of 74 (92%) PV patient sera.

CONCLUSIONS

In the largest series of combined oral DIF results in patients with MMP and PV, we have shown that NBPB is equivalent to PLB for the diagnosis of PV and multisite MMP, and is more sensitive than both histology and IIF. What's already known about this topic? The variation in sensitivity of oral biopsy sites for direct immunofluorescence (DIF) in the diagnosis of oral MMP and PV has not been studied in detail in large series of patients. Biopsy can be challenging due to difficult access and fragility of the oral mucosa. The diagnostic biopsy technique is therefore critical. What does this study add? We have shown that a normal buccal punch biopsy (NBPB) from uninvolved oral mucosa is as sensitive as a perilesional biopsy (PLB) for diagnosis of oral PV, and superior to serology and histology. For multisite MMP, NBPB is equivalent to PLB and is more sensitive than serology and histology. The oral punch biopsy technique on uninvolved buccal mucosa tissue is a simple and safe practical method for diagnosing oral PV and MMP.

Rabdomyosarcoma of the Mandible: An Uncommon Clinical Presentation

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and adolescents. Most patients present with a mass in the head and neck region, urogenital region, or with distal extremity involvement. The authors describe a challenging case of a 6-year-old male patient presenting with mandibular RMS. The clinical/radiographic/tomographic evaluations classified the tumor as an advanced stage (stage IV), with a mass of 6.0 cm involving the left side of the mandible and parotid region. The biopsy revealed round, spindled, and pleomorphic cells with hyperchromatic nuclei and rare larger rhabdomyoblasts with eosinophilic cytoplasm. The diagnosis was of embryonal RMS. The patient was referred for treatment with cycles of chemotherapy; however, pulmonary and bone marrow metastasis were identified. Radiotherapy and local surgery with microvascular reconstruction were performed later; however, the patient died after a few months. Early diagnosis is critical for a good prognosis and cure of patients with RMS. Correct diagnosis considering also the histological subtype is important for adequate treatment, which according to the literature is not uniform probably because of the rarity of this neoplasm.

High-Yield Vulvar Histopathology for the Clinician

Certain adjustable factors may influence how helpful a pathology report is to the clinician. Different biopsy techniques may be preferable based on the type of lesion being biopsied and the background epithelial surface. Key observations from the history and physical examination, possibly with a clinical photograph, are helpful to the pathologist. When reading the pathology report, realize the difficulties arising from definitively classifying some diseases and how treatment can affect the tissue. Finally, avoid miscommunication with the pathologist by understanding current nomenclature of vulvar disease.

Immunohistochemical expression of p53 and its clinicopathological correlation with modified Anneroth's histological grading system

Introduction and Objectives:

Oral squamous cell carcinoma (OSCC) is an epithelial neoplasm generally beginning as focal overgrowth of altered stem cells near the basement membrane, moving upward and laterally, replacing the normal epithelium. Histopathological grading has been used for many decades in an attempt to predict the clinical behavior of oral squamous cell carcinoma. In the present study, Forty biopsies were studied for histological grading and p53 expression. The p53 expression was studied in relation to clinical parameters such as age, sex of patient and site of tumors. Relation between histological grade of malignancy and p53 protein expression was analysed. All cases were classified according to Anneroth's histological malignancy grading system (1987).

Materials and Methods:

40 cases of OSCC were assessed for clinical parameters, Anneroth's histological grading and immunohistochemically stained with p53 protien.

Statistical Analysis:

The results obtained were analyzed using Spearman's Co-relation.

Observations and Results:

The positive expression of p53 was found in 62% of carcinomas studied. Positivity of p53 showed correlation with histological grade of malignancy and with individual parameters like degree of keratinization, nuclear polymorphism, number of mitoses and lymphoplasmacytic infiltration while showed a negative correlation with pattern of invasion.

Conclusion:

Our study showed a significant correlation between parameters of tumor cell population, lymphoplasmacytic infiltration and p53 expression. A significant association between high grade of malignancy and p53 overexpression and insignificant correlation of p53 with age, sex of the patient and site of the tumor was found.

Gingival fibromatosis: clinical, molecular and therapeutic issues

Gingival fibromatosis is a rare and heterogeneous group of disorders that develop as slowly progressive, local or diffuse enlargements within marginal and attached gingiva or interdental papilla. In severe cases, the excess tissue may cover the crowns of the teeth, thus causing functional, esthetic, and periodontal problems, such as bone loss and bleeding, due to the presence of pseudopockets and plaque accumulation. It affects both genders equally. Hereditary, drug-induced, and idiopathic gingival overgrowth have been reported. Hereditary gingival fibromatosis can occur as an isolated condition or as part of a genetic syndrome. The pathologic manifestation of gingival fibromatosis comprises excessive accumulation of extracellular matrix proteins, of which collagen type I is the most prominent example. Mutation in the Son-of-Sevenless-1 gene has been suggested as one possible etiological cause of isolated (non-syndromic) hereditary gingival fibromatosis, but mutations in other genes are also likely to be involved, given the heterogeneity of this condition. The most attractive concept of mechanism for drug-induced gingival overgrowth is epithelial-to-mesenchymal transition, a process in which interactions between gingival cells and the extracellular matrix are weakened as epithelial cells transdifferentiate into fibrogenic fibroblast-like cells. The diagnosis is mainly made on the basis of the patient's history and clinical features, and on histopathological evaluation of affected gingiva. Early diagnosis is important, mostly to exclude oral malignancy. Differential diagnosis comprises all pathologies in the mouth with excessive gingival overgrowth. Hereditary gingival fibromatosis may present as an autosomal-dominant or less commonly autosomal-recessive mode of inheritance. If a systemic disease or syndrome is suspected, the patient is directed to a geneticist for additional clinical examination and specialized diagnostic tests. Treatments vary according to the type of overgrowth and the extent of disease progression, thus, scaling of teeth is sufficient in mild cases, while in severe cases surgical intervention is required. Prognosis is precarious and the risk of recurrence exists.

Diagnostic procedures for autoimmune vesiculobullous diseases: A review

Oral soft tissues are affected by numerous pathologic conditions of variable etiology and hence their appropriate management relies on their accurate diagnosis. Clinical identification of intact vesicle and bulla in the oral cavity is really a challenge due to the regular irritation and the friable nature of oral mucosa. Rupture of these lesions leads to erosions or ulcerations on the surface, hence making the diagnosis of vesiculobullous (VB) lesions is even more difficult due to the fact that the differential diagnosis along with VB lesions will also include ulcerative, immunological-mediated diseases, and neoplasms and systemic diseases. Hence, knowledge of the clinical presentation of these disorders and the relevant diagnostic procedures is important not just for dermatologists, but also for general practitioners and dentists. In this article, the various procedures have been explained that can be used for the diagnostic purpose of VB lesions.

Effectiveness of Toki's criteria and determination of variables for identification of HPV L1 protein in oral lesions

Objectives: To evaluate the effectiveness of Toki’s criteria in identifying the HPV L1 protein in oral lesions with the use of immunohistochemistry (IHC) and to determine which criteria optimize such identification. Study Design: Retrospective study of 277 cases diagnosed as HPV lesions at 22 years. Tests of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), kappa coefficients, and chi2 values, as well as two logistic regression analyses (p≤0.05), were conducted. Results: Of the lesions studied, 96.4% (267 of 277) were positive for HPV using Toki’s criteria and 28.5% (79 of 277) were positive for L1 by IHC. Toki’s criteria showed sensitivity=93.67%, specificity=2.53%, PPV=6.99%, and NPV=46.55%. Neither concordance nor statistically significant associations were observed between both tests. The logistic regression of Toki’s criteria was useful in the diagnosis of L1, correctly classified 71.8% of the lesions positive for L1, and showed a Hosmer-Lemeshow adjustment of p=0.614 and a Nagelkerke’s coefficient of determination of 6.8%. The explanatory variables statistically significant at p≤0.05 were dyskeratosis (p=0.01) and papillomatosis (p=0.04). Forty-nine independent variables (clinical and histopathologic) were involved in the second regression analysis. The model correctly classified 85.2% of the lesions and showed a Hosmer-Lemeshow adjustment of p=0.696 and a Nagelkerke’s coefficient of determination of 60.2%. The explanatory variables statistically significant atp≤0.05 were: age younger than 35 years (p=0.001), multiple lesions (p=0.031), hyperorthokeratosis (p=0.019), focal intracellular edema (p=0.002), and the presence of 1 to more than 5 cells with degenerative changes in their nucleus (p=0.048). Conclusions: Toki’s criteria are not adequate to make a diagnosis of lesions by HPV in the mouth, but the logistic regression analysis showed clinical and histopathologic variables which optimize the identification of lesions through the L1 protein. However, a PCR study is advisable when the presence of high-risk HPV is suspected.

Key words:HPV, Toki’s criteria.

A study on oral mucosal lesions in 3500 patients with dermatological diseases in South India

BACKGROUND

Oral mucosal lesions that are observed in the dermatological diseases are categorized under mucocutaneous conditions. The oral lesions in dermatological diseases may be the early aspects of the disease manifestation or the most significant clinical appearance or the only sign/and or symptom of such dermatological diseases and occasionally lesions occur simultaneously in the skin as well as mucous membrane.

AIM

This present study attempts to find out the prevalence of oral mucosal lesions in patients with dermatological diseases.

SUBJECTS AND METHODS

The study includes 3500 patients who attended out-patient Department of Dermatology. Patients with oral manifestation were subjected for clinical examination in the Department of Oral Pathology. Diagnostic procedures were performed to confirm the clinical oral diagnosis. The results of the study were analyzed by SPSS software version 19.0 (Armonk, NY) and presented as descriptive statistics. Correlation of oral manifestions with their respective dermatological disease was statistically analysed by Pearson's correlation test.(P < 0.05 were considered as statistically significant).

RESULTS

The prevalence rate of oral mucosal lesions in the present study was 1.8% (65/3500). The most frequent lesions observed were psoriasis 32.3% (21/65), lichen planus 18.4% (12/65), Stevens Johnson Syndrome 18.4% (12/65), pemphigus 10.7% (7/65), toxic epidermal necrolysis 4.6% (3/65), systemic lupus erythematosus 3% (2/65), discoid lupus erythematosus 1.5% (1/65), pemphigoid 1.5% (1/65). Gender distribution in the study population was statistically significant (P < 0.001). Employed and unemployed individuals in the study population were statistically significant (P < 0.001). Pearson's correlation analysis of oral manifestations with their respective dermatological disease showed r = 0.466 and signifies a positive correlation and is statistically significant at the 0.01 level (two-tailed).

CONCLUSION

The prevalence rate of oral mucosal lesions in patients with dermatological diseases was relatively low. However, predominant oral mucosal lesions observed in the study were autoimmune in origin with a high morbidity and mortality index. Hence, multidisciplinary approach will definitely help in the prognosis of patients.

Garbage in, garbage out: a critical evaluation of strategies used for validation of immunohistochemical biomarkers

The use of immunohistochemistry (IHC) in clinical cohorts is of paramount importance in determining the utility of a biomarker in clinical practice. A major bottleneck in translating a biomarker from bench-to-bedside is the lack of well characterized, specific antibodies suitable for IHC. Despite the widespread use of IHC as a biomarker validation tool, no universally accepted standardization guidelines have been developed to determine the applicability of particular antibodies for IHC prior to its use. In this review, we discuss the technical challenges faced by the use of immunohistochemical biomarkers and rigorously explore classical and emerging antibody validation technologies. Based on our review of these technologies, we provide strict criteria for the pragmatic validation of antibodies for use in immunohistochemical assays.

Current concepts of immunofluorescence in oral mucocutaneous diseases

Aim:

To study the immunofluorescence pattern and to assess its reliability as a confirmatory diagnostic test in patients with pemphigus, pemphigoid, lichen planus, and lupus erythematosus and also to assess the disease activity by indirect immunofluorscence (IIF) in patients with pemphigus only.

Materials and Methods:

Twenty-six patients were included in the study group, out of which, 6 patients were clinically and histopathologically diagnosed as pemphigus, completely free of active lesions were subjected to IIF only to assess the disease activity and were grouped separately. Based on the clinical and provisional diagnosis, the remaining 20 patients who had active lesions were subjected to direct immunofluorscence (DIF) and IIF and were divided into four groups. Biopsy specimens were taken from the periphery of the lesions and were examined by both conventional light microscopic and DIF methods. Five milliliters of venous blood was collected from each patient and were subjected to IIF.

Results:

Histopathological diagnosis was consistent with direct immunofluorescence study in 15 cases (75%). The various immunofluorescence patterns observed in our study were consistent with those described by various authors in standard textbooks and articles.

Conclusion:

Histopathology remains gold standard for most of the diseases, it is recognized from this study that not all lesions are amenable to definitive histopathological diagnosis thus; DIF can provide a valuable additional criterion in diagnosis.

Essentials Before Sending Biopsy Specimens: A Surgeon's Prespective and Pathologists Concern

Pathology is a science, which deals with the scientific study of structure and function of the body in disease. It involves both macroscopic and microscopic study of the tissue correlating it with the clinical and radiographic history, thus helping to arrive at an accurate diagnosis. Proper history and clinical description of the excised specimen has to be conveyed to the pathologist. More than proper surgical technique is required to facilitate the proper diagnosis of an oral biopsy specimen. The proper preparation of the tissue for microscopic analysis depends on steps taken by the surgeon, assistant, and histotechnician to reduce the inclusion of artifacts. This article particularly deals with various requirements for proper handling and transportation of specimens, important things which are to be communicated to pathologists, and various methods used to preserve the tissue for use in latest techniques.

The role of immunofluorescence in the physiopathology and differential diagnosis of recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is a disease characterized by the periodic appearance of aphthous lesions on the oral mucosa, of which etiology and physiopathology are not well explained. Recent studies with direct immunofluorescence show controversial results. Some reveal that the basic disorder is associated with humoral immunity, while others point to changes in cellular immunity. Atypical forms of aphthous stomatitis may have its differential diagnosis carried out with vesicobullous diseases, such as pemphigus vulgaris.

AIM

Check the presence of immunocomplexes in the mucosa of patients with aphthous stomatitis and the usefulness of the differential diagnosis method with bullous skin diseases.

MATERIALS AND METHODS

23 patients with aphthous stomatitis were prospectively included in the study. There were all submitted to mucosa biopsy under local anesthesia for the removal of two fragments. One of these was sent to histology and, the other to direct immunofluorescence.

RESULTS

The 23 samples from the histology exam revealed an ulcerated inflammatory process. The samples referred to immunofluorescence resulted negative and only one showed the presence of complement in the basal membrane.

CONCLUSION

Based on our results, we conclude that the patients with RAS do not show deposits of immunocomplexes in their oral cavity mucosa and immunofluorescence is useful in the differential diagnosis between this disease and bullous skin diseases.

Assessment of angiogenic markers in oral hemangiomas and pyogenic granulomas

The purpose of this research was to evaluate the immunohistochemical expression of the vascular endothelial growth factor (VEGF-C1) and measuring the angiogenic activity by the staining for von Willebrand factor (vWF) and CD31 in oral pyogenic granulomas and hemangiomas. The results showed that there was no statistically significant difference in the angiogenesis index between the lesions evaluated. The average microvessel density determined for MVC (microvessel count) using CD31 was 60.64 for hemangiomas and 59.64 for pyogenic granulomas, while angiogenic index determined using vWF was 64.24 and 62.20 in these lesions. The results showed that the cells highlighted by staining for vWF were more uniform than in those stained for CD31. There was no statistically significant difference between the lesions for the number of cells highlighted by staining for VEGF-C1. However, the mean number of cells highlighted in pyogenic granuloma specimens was higher (153.23) when compared to oral hemangioma specimens (115.17). The VEGF-positive cells were endothelial cells and fibroblasts in hemangiomas and macrophages and fibroblasts in pyogenic granulomas. These results effort the role of the angiogenic factors in the etiopathogenesis of the hemangiomas and pyogenic granulomas, however, it showed that microvessel quantification is not useful in the differential diagnosis of these lesions.

Diagnosis of periodontal manifestations of systemic diseases

Many systemic diseases can mimic periodontitis or gingivitis. These include many immunologic, infectious, neoplastic and metabolic disorders. In comparison with periodontitis and gingivitis, these disorders are considerable less common. However, since their diagnosis and management differ, a high index of suspicion is frequently needed when confronted a patient presenting with gingival or periodontal disease. This chapter has reviewed a number of systemic conditions that may mimic clinically both gingivitis and chronic periodontitis and has focused on the features that may assist the clinician in making the diagnosis and providing specific therapies.