Effect of radiotherapy on oral mucosa assessed by quantitative exfoliative cytology

A brief review of cytology in dentistry

Oral cytology is a non-invasive adjunctive diagnostic tool with a number of potential applications in the practice of dentistry. This brief review begins with a history of cytology in medicine and how cytology was initially applied in oral medicine. A description of the different technical aspects of oral cytology is provided, including the collection and processing of oral cytological samples, and the microscopic interpretation and reporting, along with their advantages and limitations. Applications for oral cytology are listed with a focus on the triage of patients presenting with oral potentially malignant disorders and oral mucosal infections. Furthermore, the utility of oral cytology roles across both expert (for example, secondary oral medicine or tertiary head and neck oncology services) and non-expert (for example, primary care general dental practice) clinical settings is explored. A detailed section covers the evidence-base for oral cytology as a diagnostic adjunctive technique in both the early detection and monitoring of patients with oral cancer and oral epithelial dysplasia. The review concludes with an exploration of future directions, including the integration of artificial intelligence for automated analysis and point of care 'smart diagnostics', thereby offering some insight into future opportunities for a wider application of oral cytology in dentistry.

Cytomorphometric Analysis of Oral Buccal Mucosa of Dental Colleges' Students in Sulaimani City

This study evaluates the cytomorphometric measures of cells obtained from the buccal mucosa of dental students to assess the fluctuation of the cellular characteristics among relatively normal subjects, with any potential correlations with demographic information, different habits, and hormonal disturbance. This prospective study included 100 dental students with no detectable oral alterations submitted to brush cytology. The smears were fixed with 95% ethyl alcohol and stained with hematoxylin and eosin stain. The stained section was observed under an image analyzer for cytomorphometric analysis. Cytopathological observations were recorded, including inflammation, microbial colonies, micronuclei, keratinization, overlapping, and hemorrhage. Chi-square tests were applied for non-parametric variables. One-way analysis of variance (ANOVA) was used to compare the cytometric parameters to habits and hormonal disturbances. A p-value < 0.05 was considered statistically significant. The results showed close proximity among subjects in the matter of cytomorphometric measures; no significant influence of sex, smoking, alcohol drinking habits, and menstruation was found on cytomorphometric diameters or cytopathological observation, and vice versa, while polycystic ovary syndrome impacted nuclear and nuclear-cytoplasmic ratio (p = 0.003, p = 0.02), respectively. Oral exfoliative cytology combined with cytomorphometric analysis for the studied normal individuals can be helpful in various investigations of oral and systemic diseases.

Karyoanomalic frequency assay during radiation therapy – A promising marker in the prognosis of oral and oropharyngeal carcinoma

Introduction:

Radiotherapy is commonly used in the treatment of oral and oropharyngeal carcinomas, either alone or in combination with other modalities of treatment like surgery/chemotherapy. It is always essential to know the nature of tumor response to the irradiation for successful outcomes and prognosis. With this view, the study has been conducted to document the usefulness of nuclear changes, karyolysis (KL), and karyorrhexis (KR) in particular as prognostic markers during the treatment.

Materials and Method:

Sixty patients, aged between 28 and 73 years (56 males and 4 females) years, histopathologically confirmed cases of oral and oropharyngeal carcinoma of different degrees of differentiation, were included in the study. The mode of treatment for the patients was radiotherapy with a radiation dose plan of 4 Gy, 14 Gy, 24 Gy, and 60 Gy on the 2^nd, 7^th, 12^th, 30^th days, respectively. The mucosal scrapings obtained from the site of the lesion at each interval were stained with Giemsa and May-Grunwald's stain. The stained slides were studied to assess the frequency of KL and KR.

Results:

It was observed that there was no significant difference between the site of lesion and tumor differentiation with the frequency of KL or KR. However, there was a statistically significant difference in the KL and KR indices with each interval of treatment. The percentage of relative increment among both the studied parameters was also significant, indicating their efficiency as a promising prognostic marker in radiotherapy.

Conclusion:

Hence, assessment of KL and KR at different intervals of time during radiotherapy could be used as an efficient tool to determine the radiosensitivity and prognosis in oral and oropharyngeal carcinoma patients.

Abnormal Nuclear Variations in Response to Radiotherapy- As a Tool in Treatment Planning and Assessment of Prognosis

INTRODUCTION

The treatment approaches for oral squamous cell carcinoma (OSCC) include single management with surgery, radiotherapy, along with chemotherapy or various combinations of these modalities. The estimation of radio sensitivity of individual tumours is essential for planning the optimum radiation schedule for each patient. Assessment of radiation induced histo morphological changes in the nucleus is a known marker of radiosensitivity.

AIM

The aim of this study was to establish the relationship between nuclear changes with radiation dose and to investigate the prospect of utilizing them as an assay to predict tumour response to radiotherapy in oral cancers.

MATERIALS AND METHODS

The present study included 50 patients (age range of 30-65yrs) with histopathologically confirmed squamous cell carcinoma of oral mucosa and being treated by radiotherapy alone with a radiation dose schedule of 4, 14, 24 and 60 Gy respectively at 2(nd), 7(th), 12(th) and 30(th) day. From the included patients, smear of the buccal mucosa was collected and was air dried and fixed with methanol. The Nuclear changes of Micronucleus (MN), Nuclear Budding (NB) and Multinucleation (MNU) were evaluated under the bright field microscopy after staining with Giemsa and May-Grunwald's stain.

RESULTS

Out of the 50, 37(74%) were males and 13(26%) were females (Ratio 3:1). The mean percentage increase of MN and MNU were found to be statistically significant (p=0.001) when compared with pre-treatment day. Similar findings were seen with NB, except between pretreatment and after 14 Gy (p-0.110). In the present study the measurement of relative increment index done in respect to all nuclear abnormalities show a sustained increase with increasing dosage of radiation.

CONCLUSION

The present study, was undertaken to explore the possibility of establishing a relationship between the frequencies of nuclear abnormalities in patients with oral cancer with applied dosage and duration of radiotherapy. The progressive increase in Micronucleus and Multinucleation indices with increasing dose of radiation proves that these parameters can be used as indicators for assessing the response of tumour for radiotherapy. These parameters can be used as prognostic indicator in oral carcinoma cases undergoing radiotherapy.

Cytological Study of Breast Carcinoma Before and After Oncotherapy with Special Reference to Morphometry and Proliferative Activity

Our study was done to assess the cytological changes due to oncotherapy in breast carcinoma especially on morphometry and proliferative activity. Cytological aspirates were collected from a total of 32 cases of invasive ductal carcinoma both before and after oncotherapy. Morphometry was done on the stained cytological smears to assess the different morphological parameters of cell dimension by using the ocular morphometer and the software AutoCAD 2007. Staining was done with Ki-67 and proliferating cell nuclear antigen (PCNA) as proliferative markers. Different morphological parameters were compared before and after oncotherapy by unpaired Student's t test. Statistically significant differences were found in morphometric parameters, e.g., mean nuclear diameter, mean nuclear area, mean cell diameter, and mean cell area, and in the expression of proliferative markers (Ki-67 and PCNA). Statistical analysis was done by obtaining p values. There are statistically significant differences between morphological parameter of breast carcinoma cells before and after oncotherapy.

Efficacy of oral exfoliative cytology in diabetes mellitus patients: a light microscopic and confocal microscopic study

AIM

Diabetes mellitus (DM) has become a global problem. By monitoring the health status of these individuals, diabetic complications can be prevented. We aimed to analyze alterations in the morphology and cytomorphometry of buccal epithelial cells of type 2 DM patients using oral exfoliative cytology technique and determine its importance in public health screening, diagnosis and monitoring of diabetes mellitus.

MATERIALS AND METHODS

The study was carried out in 100 type 2 DM patients and 30 healthy individuals. Smears were taken from the right buccal mucosa and stained by the Papanicolaou technique. Staining with Acridine orange was carried out to view qualitative changes with confocal laser scanning microscope (LSM-510 Meta). The cytomorphometry was evaluated using IMAGE PRO PLUS 5.5 software with Evolution LC camera. All findings were statistically analyzed.

RESULTS

The results showed that with increase in fasting plasma glucose levels, there is significant increase in nuclear area, decrease in cytoplasmic area, and increase in nuclear cytoplasmic ratio (p < 0.05) when compared to the control group. Various qualitative changes were noted, such as cell degeneration, micronuclei, binucleation, intracytoplasmic inclusion, candida and keratinization.

CONCLUSION

In the present study, we found significant alterations in the cytomorphometry and cytomorphology of buccal epithelial cells of type 2 DM patients. This study supports and extends the view that these cellular changes can alert the clinician to the possibility of diabetes and aid in monitoring of diabetes throughout the lifetime of the patient.

The role of tobacco as an etiological agent for oral cancer: Cytomorphometrical analysis of the buccal mucosa in tobacco users

BACKGROUND

Histopathological diagnosis of lesions arising from the intake of tobacco is based on subjective evaluation of morphological alterations within the lesional tissue. Oral exfoliative cytology is a non-invasive diagnostic technique for early detection of oral premalignant and malignant lesions. Morphometric techniques have been advocated as objective and reproducible methods of detecting changes before they are visible by routine microscopy and can facilitate differentiation of normal and abnormal epithelium. This study was conducted to assess the morphometric parameters (cell diameter, nuclear diameter and nuclear cytoplasmic ratio [N:C ratio]) in tobacco smokers and chewers and to evaluate the variations, if any.

MATERIALS AND METHODS

The study was conducted on cytological smears obtained from oral lesions of patients with habit of tobacco smoking (Group B) and tobacco chewing (Group C). Group A comprised of subjects free from oral lesions and not using tobacco in any form. Patients with both the habits were excluded. The smears were stained using Papanicoloaou staining method. For morphometric analysis, Microimage 3.0 image analysis software was employed. The statistical test employed was an analysis of variance and P < 0.05 was considered as significant.

RESULTS

The results of this study showed that the cellular diameter was progressively reduced and nuclear diameter progressively increased from Group A to Group B to Group C. The N:C ratio also showed a progressive increase from Group A to Group C.

CONCLUSION

The results confirmed that tobacco chewing and smoking influenced the cytomorphology of normal appearing buccal mucosa and the degree of these changes were found to be greater in chewers as compared to smokers.

Evaluation of nuclear morphometry and DNA ploidy status for detection of malignant and premalignant oral lesions: quantitative cytologic assessment and review of methods for cytomorphometric measurements

PURPOSE

Detection of a precancerous or cancerous lesion when small is one of the most important factors to improve 5-year survival rates of oral cancer. Although surgical biopsy is the most definitive method for diagnosing oral lesions, it is impractical to routinely subject large numbers of patients to biopsy. Recently, cytomorphometric assessments improved by advanced computer-assisted image analysis systems have gained importance. This study was established to evaluate the efficacy of nuclear cytomorphometric analysis and DNA ploidy status for the detection of oral malignancies. Methods used for cytomorphometric analysis were also reviewed.

PATIENTS AND METHODS

Oral mucosal smears (n = 44) were obtained from patients (n = 22) presenting with various oral lesions using a cytobrush immediately before biopsy. Cytomorphometric measurements and nuclear Feulgen DNA content analysis were carried out after the Feulgen staining procedure. Smears from the lesion site constituted the study group whereas contralateral healthy mucosal sites served as control.

RESULTS

DNA ploidy analysis revealed 20 diploid (90.9%) and 2 aneuploid DNA patterns (9.1%) sampled from the lateral margin of the tongue and floor of the mouth. When only malignant lesions were considered, aneuploidy rate was 16.7% whereas a diploid pattern was indicated for 83.3% of the sample. With cytomorphometric measurements, a statistically significant difference was shown for nuclear perimeter, area, diameter equivalent to circle, minimum and maximum Feret, intensity, DNA content (c) and DNA index values.

CONCLUSIONS

Cytomorphometric analysis via oral brush biopsy is a valuable adjunct to biopsy for identification of premalignant and early stage cancerous oral lesions as a rapid and minimally invasive procedure with high specificity and sensitivity rates, requiring no topical or local anesthetic.

Effect of alcohol on the oral mucosa assessed by quantitative cytomorphometry

The effect of alcohol on the oral mucosa was assessed using quantitative cytomorphology applied to smears taken from clinically normal oral mucosa of patients attending an alcohol problem unit and results were compared to a control group (consisting of social and non-drinkers) attending a hospital for routine dental care. Smears were stained using the Papanicolaou method and the nuclear and cell boundaries of 50 randomly selected cells traced and mean areas (NA and CA, respectively) calculated. The average number of units of alcohol consumed were recorded for each group together with relevant blood tests. The alcohol group was further subdivided into "binge" and "regular" drinkers. No significant differences were found between mean NA and mean CA values for these two types of alcohol drinkers, despite a marked difference in weekly units consumed. However, a statistically significant reduction in mean cytoplasmic area (P < 0.001) and mean nuclear area (P < 0.01) was found for the alcohol group when compared to controls. In conclusion, excess alcohol intake may influence results for quantitative oral cytomorphology. Further research is indicated on the relative effects of alcohol (both topical and systemic).

Oral exfoliative cytology: review of methods of assessment

The use of oral exfoliative cytology in clinical practice declined due to the subjective nature of its interpretation and because there may be only a small number of abnormal cells identifiable in a smear. The more recent application of quantitative techniques, together with advances in immunocytochemistry, have refined the potential role of cytology, stimulating a reappraisal of its value in the diagnosis of oral cancer. This review considers the influence of the quantitative analysis of cytomorphology, DNA analysis and other tumour markers applied to oral exfoliative cytological samples. These studies indicate that oral cytology may provide an important adjunct in the assessment of the patient with a potentially cancerous oral lesion.

Performance of a computer simulated neural network trained to categorise normal, premalignant and malignant oral smears

The accurate detection of malignant neoplasms whilst they are still small is recognised as one of the main factors increasing chances of survival. Neural networks have many biomedical applications and they have been applied to neoplasia but their use in oral pathology has only recently been documented. The objectives of this study were to train networks to discriminate between normal and dysplastic mucosa. Each network was trained by back propagation, internal cross validation and tested on additional data. The data were derived by analysing 348 intra-oral smears and included mean nuclear and mean cytoplasmic areas of the smears measured by image analysis. A neural network differentiated between normal/non-dysplastic mucosa and dysplastic/malignant mucosa (specificity 0.82, sensitivity 0.76). These early results suggest that integrating neural networks and image analysis, as well as investigating additional criteria, could enhance automation and accuracy of smear techniques in diagnosing oral malignancy.

Morphological and morphometric studies of exfoliated oral squames from chronic inflammatory oral ulcers using light and scanning electron microscopy

The morphological and morphometric features of exfoliated squames from the margins of chronic oral ulcers were studied by light and scanning electron microscopy. A variety of features consistent with a mixture of degenerative changes and regenerative activity were observed. None was sufficiently reliable to distinguish chronic inflammatory from malignant ulcers.

The prognostic significance of hyperploid cells in squamous carcinoma of the uterine cervix treated with radiotherapy

Smears were obtained from patients undergoing radiotherapy for Stage I-IV squamous cell carcinoma of the cervix. The presence of cells with large or multiple nuclei in smears taken during or not more than 1 month following therapy was found to be associated with a significantly increased risk of early relapse.

Photodynamic therapy of malignant and premalignant lesions in patients with 'field cancerization' of the oral cavity

The management of patients with 'field cancerization' of the oral mucosa, with multicentric foci of invasion, presents a considerable problem for the head and neck surgeon. Surgical resection of synchronous or metachronous primary squamous cell carcinomas, along with adjacent premalignant lesions, is likely to be associated with considerable mutilation. Photodynamic therapy (PDT) has been shown to be of value in the treatment of superficial tumours in the upper aerodigestive tract, with excellent healing of treated areas. This study reports the use of PDT to treat 11 patients with 'field cancerization' occurring in the oral cavity. Six patients had multiple primary cancers and five had single primary tumours. All had associated areas of leukoplakia. Each received Photofrin 2 mg/kg 48 hours prior to photoirradiation with 50-100 J/cm2 red laser light by surface illumination. Six to eight weeks later treated areas in 10 of the 11 patients showed a complete response to PDT; one patient had areas of residual leukoplakia. Two patients developed further areas of leukoplakia or erythroplakia within 12 months but no patient has had evidence of recurrent invasive carcinoma in the treated areas. Longer term follow-up will be necessary to exclude further recurrence. It is concluded that PDT offers an effective repeatable treatment option, whether on its own or as an adjunct to local excision, for patients with 'field cancerization' of the oral cavity.

Keratin profiles of normal and malignant oral mucosa using exfoliative cytology

AIMS

To assess keratin profiles from smears of malignant and contralateral normal oral mucosa as part of the development of a screening procedure for oral cancer based on exfoliative cytology.

METHODS

Smears were taken from oral cancers (confirmed by biopsy) and from the contralateral site of 20 patients. Using a panel of antikeratin antibodies, the keratins expressed by these cells were identified using a standard immunocytochemical technique (Vectastain) and assessed on a 3 point scale.

RESULTS

Using chi 2 analysis, noticeable differences between the keratin profiles for malignant mucosal smears compared with the contralateral mucosal smears were found. This was particularly evident for the simple epithelial keratins.

CONCLUSION

Individual keratins can be identified in smears from oral cancers. The identification of simple epithelial keratins seem to be the best keratin markers associated with malignancy. Their detection within smears from oral lesions could be valuable in the early diagnosis of oral cancer.

Prognostic value of PCNA and cytokeratins for radiation therapy of oral squamous cell carcinoma

In a retrospective pilot study we compared morphologically the first biopsies of 20 patients suffering from oral squamous cell carcinoma (OSCC) where preoperatively performed radiation therapy [gamma rays (cobalt-60)] was successful with 20 patients who underwent the same therapy without the expected success. All specimens were formalin fixed and paraffin embedded. We performed haematoxylin and eosin staining and immunohistochemistry (ABC-method) applying broad spectrum cytokeratin, cytokeratin (CK) 1 + 2, 3 + 6, 13 and anti-proliferating cell nuclear antigen (PCNA, PC10). The specimens of the patients with success of the radiotherapy showed statistically higher levels of PCNA positive tumour cells, measured by a computerised morphometric analysis system (VIDAS). These specimens showed significantly less CK 3-6 positive tumour cells than the specimens of the patients with failure of this therapy. The difference in the content of proliferating cell nuclear antigen might explain the different results of the performed radiation therapy. The difference in cytokeratin 3 + 6 expression might be linked with the different amount of benign hyperproliferation. Prospective studies are planned to prove the results.

Comparison of planimetry and image analysis for the discrimination between normal and abnormal cells in cytological smears of suspicious lesions of the oral cavity

Light microscope analysis of cytological smears of suspicious lesions of the oral cavity is used as a method for detecting early cancer in the oral cavity. The sensitivity of this approach can be improved by quantitative analysis of the cells in the cytological smears. We have compared the efficiency of planimetry and the Vids V system of image analysis, as quantitative methods for discriminating between normal and abnormal cells in cytological smears of suspicious lesions in the oral cavity. Both methods detected an increase in nuclear area and a decrease in cytoplasmic area in abnormal epithelial cells from dysplastic lesions of increasing severity. However, image analysis was better able to discriminate between benign and malignant cells on the basis of nuclear size. Thus the Vids V system of image analysis is more appropriate than planimetry for quantitative analysis of cytological smears from the oral cavity.

Detection of field change in oral cancer using oral exfoliative cytologic study

Four smears were taken from the normal buccal mucosa of 55 oral cancer patients and 76 cancer-free patients. In each case, two were stained by the Papanicolaou method and two underwent Feulgen hydrolysis. Quantitative assessment of nuclear area (NA) and cytoplasmic area (CA) of the Papanicolaou smears was undertaken using a semiautomatic image analysis system. DNA profiles were assessed from the Feulgen smears using a Vickers M85 microdensitometer (Vickers Instruments, York, England) and were found to be diploid for all patients. Results were then analyzed with respect to those patients who took alcohol, tobacco, combination of alcohol and tobacco, and those who took neither. A significant reduction in CA for the oral cancer group (P equals 0.001) but no change in NA (P equals 0.74) was observed. A detailed analysis of alcohol and tobacco habits could identify no significant role for these two factors, in the reduction in cytoplasmic area. Such field change may prove to be of value in predicting the development of second malignant tumors.

Evidence of field change in oral cancer

Evidence of field change in oral cancer was assessed using quantitative cytomorphometric analysis of smears taken from normal buccal mucosa in oral cancer and cancer-free patients. The nuclear areas (NA) and cytoplasmic areas (CA) were calculated using a semi-automatic image analysis system. A statistically significant reduction in CA (p = 0.002) but no change in NA was observed for the oral cancer group. This change occurred irrespective of tobacco and alcohol usage. We believe this to be the first evidence for true field change since Slaughter's original hypothesis in 1946.

Quantitative exfoliative cytology of normal buccal mucosa: effect of smoking

The effect of cigarette smoking on the oral mucosa was assessed through the application of quantitative cytomorphometric analysis to smears obtained from clinically normal buccal mucosa. The nuclear (NA) and cytoplasmic (CA) area of cells within each smear were measured using a Vids V semi-automatic image analysis system. Mean values for NA (smokers--78.74 microns 2, non-smokers--72.28 microns 2 and for CA (smokers--3273.9 microns 2, non-smokers--3098.96 microns 2) were obtained. A two-sample t-test revealed a significant elevation in NA for smokers, but no significant variation in CA between the two groups. These results would suggest that for normal buccal mucosa smoking does appear to influence cytomorphology.

Quantitative assessment of various fixatives on nuclear and cytoplasmic areas in oral cytology

Both nuclear and cytoplasmic areas are parameters known to be of significance in the diagnosis of malignancy. However, few studies have assessed the effect of fixation on exfoliative cytology and none has looked at such influences upon oral smears. Hence the method of fixation may influence directly diagnostic cytology. The effect of three methods of fixation upon the nuclear and cytoplasmic areas of cells removed from the buccal mucosa was quantitatively assessed. The three methods employed, prior to Papanicolaou staining, were: direct immersion in diethylether and ethanol (1:1 v/v), spray fixation (Vale Smear Fix) and air drying. Three smears from each of 21 patients were used, each slide being allocated randomly a method of fixation. After 24 h all smears were processed for Papanicolaou's stain. The nuclear and cytoplasmic areas were calculated using semi-automated image analysis. No significant differences were found in the two areas whichever method of fixation was used.