Efficacy of oral brush cytology in the evaluation of the oral premalignant and malignant lesions

Adjunctive aids for the detection of oral squamous cell carcinoma and oral potentially malignant disorders: A systematic review of systematic reviews

This study presents the results of systematic reviews on adjunctive tools in screening and diagnosis of oral squamous cell carcinoma (OSCC) and oral potentially malignant disorders (OPMD) and to determine if the current literature supports their use as either an adjunctive tool or replacement of gold standard techniques. Systemic reviews and meta-analysis that evaluated adjunctive tools including chemiluminescence, tissue autofluorescence, tissue fluorescence spectroscopy, vital staining and cytology techniques were systematically examined using AMSTAR II. Twenty-seven systematic reviews were included. Five studies had a low quality of evidence, and nine studies had a critically low quality of evidence. This review found limited evidence to recommend chemiluminescence, tissue autofluorescence tools and vital staining as diagnostic tools, but only serve as clinical adjuncts to conventional oral examination. Cytology techniques and narrow-band imaging may be utilised as a non-invasive diagnostic adjunctive tool for the detection of OSCC and the malignant transformation of OPMD. In conclusion, this paper provides evidence on several types of adjunctive tools and provides recommendations on their use in clinical practice. These tools are considered useful as clinical adjuncts but there is insufficient evidence for their use as a diagnostic tool to replace gold standard conventional oral examination and surgical biopsy.

Effect of different types of smoking on oral health and on cellular changes in oral mucosa

Objectives

Smoking is known to be a major risk factor for several diseases. Recently, electronic cigarettes have been introduced to the market; however, their effect on oral health has not been well studied yet. We aim to compare the effect of different types of smoking on oral health and to evaluate cytomorphological changes in oral mucosa among different types of smokers.

Study design

A total of 112 participants were recruited, conventional cigarette smokers (n = 28), electronic cigarettes smokers (n = 26), hookah smokers (n = 29) and non-smokers (n = 29). Oral examination, brush cytology and salivary flow test were performed. Cytological smears were stained and examined for cytomorphological changes. Oral symptoms, type, and frequency of smoking were obtained through questionnaires. SPSS program was used for statistical analysis.

Results

Most of the oral symptoms reported in this study were among conventional and electronic cigarettes smokers. While hookah smokers reported the least oral symptoms. Increase in DMFT and gingival index were observed among all smokers, mainly among conventional cigarettes smokers. Conventional cigarette and hookah smokers were found to have the most significant cellular changes. Electronic cigarette smokers had certain cellular changes as well.

Conclusion

All types of smoking adversely affect oral health and can induce cellular changes in the oral mucosa.

New Horizons and Prospects in Oral Cancer Detection

Recent advancements in oral cancer detection prioritize non-invasive and minimally invasive techniques for efficient and accurate screening. This review outlines progress in methods such as narrow band imaging, fluorescence imaging, and optical coherence tomography, showing promise in early lesion detection. Biomarker detection in saliva and targeted nanoparticles enhance early diagnosis, while machine learning improves diagnostic accuracy. However, clinical validation and large-scale studies are needed for widespread adoption.

Screening of Oral Squamous Cell Carcinoma Through Color Intensity-Based Textural Features

Background Early screening and diagnosis of oral squamous cell carcinoma (OSCC) has always been a major challenge for pathologists. Artificial intelligence (AI)-assisted screening tools can serve as an adjunct for the objective interpretation of Papanicolaou (PAP)-stained oral smears. Aim This study aimed to develop a handy and sensitive computer-assisted AI tool based on color-intensity textural features to be applied to cytologic images for screening and diagnosis of OSCC. Methodology The study included two groups consisting of 80 OSCC subjects and 80 control groups. PAP-stained smears were collected from both groups. The smears were analyzed in Matlab software computed data and color intensity-based textural features such as entropy, contrast, energy, homogeneity, and correlation, were quantitatively extracted. Results In this study, a statistically significant difference was noted for entropy, energy, correlation, contrast, and homogeneity. It was found that entropy and contrast were found to be higher with a decrease in homogeneity, correlation, and energy in OSCC when compared to the control group. Receiver operating characteristic curve analysis was done and accuracy, sensitivity, and specificity were found to be 88%, 91%, and 81%, respectively. Conclusion The gray-level co-occurrence matrix (GLCM) color intensity-based textural features play a significant role in differentiating dysplastic and normal cells in the diagnosis of OSCC. Computer-aided textural analysis has the potential to aid in the early detection of oral cancer, which can lead to improved clinical outcomes.

Micronuclei detection in oral cytologic smear: does it add diagnostic value?

BACKGROUND

Screening and early diagnosis of oral squamous cell carcinoma (OSCC) are directly associated with increased survival rate and improved prognosis. Noninvasive diagnostic tools have been implemented in the early detection as toluidine blue staining, optical imaging, and oral cytology. This study aimed to assess and compare the presence of micronuclei (MN) in oral exfoliative cytology of healthy controls, subjects exposed to high-risk factors for oral cancer, subjects with oral potentially malignant lesions (OPMLs), and those with malignant oral lesions.

SUBJECTS AND METHODS

A total number of 92 subjects were divided into 46 healthy controls with no oral mucosal lesions (23 with no evidence of cancer risk factors and 23 with cancer risk factors), 23 with OPMLs and 23 with oral malignant lesions. All the 92 participants were subjected to cytological sampling for detection of MN. The final diagnosis of the oral lesions was confirmed by the histopathological picture and compared to the cytological results.

RESULTS

The results showed that the diagnostic accuracy of MN was higher in OPMLs group (95.2%). The sensitivity of MN test in malignant group was much lower (52.2%); however, all the cytological criteria of malignancy were markedly detected as compared to the OPMLs group.

CONCLUSIONS

Conventional oral cytology supported by MN is highly beneficial as adjunctive tool in the screening for early detection of dysplastic oral lesions.

Utility of Indigenous Cytology Technique in the Diagnosis of Oral Cavity Lesions using Normal Saline as a Processing Fluid: A Comparative Study

Background

Oral cancer is a major health problem in developing countries. Cytology has been widely accepted as a tool in the early diagnosis of cancer.

Objectives

To evaluate the diagnostic utility of four different cytology techniques, that is, modified brush cytology (BR) technique, brush cytology cytocentrifugation (BRCC) technique, modified scrape cytology (SR) technique, and scrape cytology cytocentrifugation (SRCC) technique and correlate the cytopathological diagnosis with the available histopathological diagnosis.

Materials and Methods

It was a prospective observational study of oral cavity lesions conducted from January 2018 to December 2018 at a rural tertiary care referral institute. Smears prepared by four different techniques, that is, BR technique, BRCC technique, SR technique and SRCC technique were evaluated using a scoring system. Normal saline was used as a processing fluid for cytocentrifugation techniques, and the cytological diagnosis was compared with an available histopathological diagnosis for concordance.

Results

Twenty-seven cases of oral cavity lesions were analyzed. Squamous cell carcinoma (55.56%) constituted the most common lesion diagnosed by cytology. Total concordance was 95.65%. Brush cytology techniques were better technique than scrape cytology techniques. Cytocentrifugation techniques were better than modified brush cytology technique and modified scrape cytology technique and the values were statistically highly significant (P<0.0001).

Conclusion

The utility of only normal saline as a processing fluid for cytocentrifugation may be considered an unexplored and prudent endeavor. This indigenously designed technique may be employed to improve the quality of cytological preparation for the evaluation of oral cavity lesions.

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.

Diagnostic Accuracy of Screening of Lip and Oral Cavity Cancers or Potentially Malignant Disorders (PMD) by Frontline Workers: A Systematic Review and Meta-Analysis

BACKGROUND

Oral cancer screening strategies help reduce associated mortality and could be performed by a trained frontline health worker (FHW). The present review aims to assess the diagnostic accuracy of commonly used screening modalities for oral cancer performed by FHW in apparently healthy individuals.

METHODS

Electronic databases PubMed, Scopus, Embase, Cochrane Library, and Google Scholar, were searched. The review included studies conducted where apparently healthy adult individuals were screened by the FHW for cancer or PMD of the lip and oral cavity by any of the four commonly used techniques - Conventional Oral Examination (COE), toluidine blue staining (TBS), Oral Cytology (OC), and Chemiluminescent Illumination (CLI).

FINDINGS

A total of 2,413 potentially relevant articles were retrieved from the search, among which five studies for COE were included in the review. Four out of those five studies were done before the year 2000. None of the studies fitted the inclusion criteria for TBS, OC, and CLI. Pooled sensitivity of oral screening by COE performed by an FHW (n=5) was 88.8% (95% CI: 71.6-96.1), whereas pooled specificity was 91.9% (95% CI: 78.3-97.3). On subgroup analysis, the pooled sensitivity and specificity of studies where the prevalence of disease was <50% (n=4) was 84.5% (95% CI: 62.6 - 94.7) and 94.1% (95% CI: 82.2 - 98.2), respectively.

INTERPRETATION

COE by trained FHW had high pooled sensitivity and specificity for screening of oral cancer and PMDs. The screening techniques TBS, OC, and CLI, were not studied for mass screening by trained FHW. COE by trained FHW could be utilized for oral screening in limited-resource settings. However, the FHW should be sufficiently trained to get the desired benefits of early detection.

FUNDING

Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Smart Diagnostics: Combining Artificial Intelligence and In Vitro Diagnostics

We are beginning a new era of Smart Diagnostics-integrated biosensors powered by recent innovations in embedded electronics, cloud computing, and artificial intelligence (AI). Universal and AI-based in vitro diagnostics (IVDs) have the potential to exponentially improve healthcare decision making in the coming years. This perspective covers current trends and challenges in translating Smart Diagnostics. We identify essential elements of Smart Diagnostics platforms through the lens of a clinically validated platform for digitizing biology and its ability to learn disease signatures. This platform for biochemical analyses uses a compact instrument to perform multiclass and multiplex measurements using fully integrated microfluidic cartridges compatible with the point of care. Image analysis digitizes biology by transforming fluorescence signals into inputs for learning disease/health signatures. The result is an intuitive Score reported to the patients and/or providers. This AI-linked universal diagnostic system has been validated through a series of large clinical studies and used to identify signatures for early disease detection and disease severity in several applications, including cardiovascular diseases, COVID-19, and oral cancer. The utility of this Smart Diagnostics platform may extend to multiple cell-based oncology tests via cross-reactive biomarkers spanning oral, colorectal, lung, bladder, esophageal, and cervical cancers, and is well-positioned to improve patient care, management, and outcomes through deployment of this resilient and scalable technology. Lastly, we provide a future perspective on the direction and trajectory of Smart Diagnostics and the transformative effects they will have on health care.

Classification of cytological samples from oral potentially malignant lesions through Raman spectroscopy: A pilot study

The potential of Raman microspectroscopy of exfoliated cells has been demonstrated for oral cancer diagnosis. In this study, brush biopsies were collected from the buccal mucosa/tongue of healthy donors (n = 31) and from oral mucosal dysplastic lesions (n = 31 patients). Raman spectra were acquired and subjected to partial least squares-discriminant analysis (PLS-DA). The patient samples could be differentiated from healthy donor samples with 96% sensitivity and 95% specificity. Furthermore, PLS-DA models were developed based on cytopathological and histopathological assessment. Low and high grade dysplasia could be discriminated with 64% sensitivity and 65% specificity based on cytopathological assessment, while 81% sensitivity and 86% specificity could be achieved when histopathological assessment was within six months of the brush biopsy sampling. Therefore, this explorative study has successfully demonstrated that Raman spectroscopy may have a role in monitoring patients with dysplasia and may reduce the need for multiple biopsies.

Association of micronuclear frequency with dysplasia and cytogenetic changes (p53 mutation and p16 expression) in oral potentially malignant disorders

Aims:

The present study evaluated the frequency of micronuclei in oral potentially malignant disorders (OPMDs) and their association with the presence of dysplasia on cytology and biopsy as well as their association with p53 mutation and p16 expression. Cytological findings of dysplastic changes in OPMDs were compared to histological diagnoses.

Material and Methods:

This was a cross-sectional, observational, descriptive study. Scrape smears (n = 74) were collected from lesions in patients with OPMDs. Punch biopsy was collected in patients showing dysplastic changes. Tissue microarray for p53 mutation and p16 expression was performed using paraffin embedded blocks. Cases were classified into grades of dysplasia using both scrape smears and biopsy. Micronuclei frequency was calculated per 100 cells using scrape smears. Mann–Whitney U test was used for correlation of cytology and histology for grade of dysplasia as well as micronuclear frequency with p53 mutation and p16 expression.

Results:

Micronuclear frequency was found to be increased in patients with dysplasia. A significant association of micronuclear frequency with dysplastic changes was seen on cytology. Sensitivity of cytological evaluation was found to be 64.7%. The association of the micronuclear frequency of samples with p53 mutation and p16 expression was nearly significant (n = 28, P = 0.069 and 0.095, respectively).

Conclusion:

Micronuclear frequency can be a reliable marker of mutagenic change in OPMDs. Cytological assessment of micronuclei can serve as useful, non-invasive, and relatively inexpensive tool to predict cancerous changes in OPMDs.

Guide flange Prosthesis for management of hemimandibulectomy

Guide flange is given to patients who have undergone surgical hemi/segmental/subtotal mandibulectomy due to various reasons (leading cause being squamous cell carcinoma), with resultant mandibular deviation. If procedures such as secondary osseous grafting are planned, the clinician has to wait for healing of the graft, lesion, or radiotherapeutic effects to abate. Only after the healing of the graft, a definitive prosthesis can be planned. During this time lag, prosthesis must be given to the patient to correct mandibular deviation on account of unilateral muscle pull. Furthermore, in certain cases, a definitive prosthesis has to be put on hold due to failure of bone grafting or when the patient is not willing for a second surgery. This report describes the fabrication of such a mandibular guide flange prosthesis.

A Cytological Study Enlightening the Unseen Effects of Concomitant Chemoradiotherapy in Contralateral Normal Buccal Mucosa of Oral Squamous Cell Carcinoma Patients

Background/objectives In patients receiving concomitant chemoradiotherapy (CCRT) as a treatment for oral squamous cell carcinoma (OSCC), cytological changes were seen not only in neoplastic epithelial cells but the non-neoplastic epithelial cells are also affected, resulting in cytopathological atypical changes. The present study was designed to observe oral epithelial atypical cytopathologic changes induced in contralateral normal buccal mucosa in OSCC patients receiving CCRT. Methods The study included 150 patients with OSCC treated by CCRT whose details were collected from the Institute of Nuclear Medicine and Oncology Lahore (INMOL) Hospital Lahore. Cytological smears were obtained from the contralateral normal buccal mucosa of OSCC patients. The serial scrape smears were taken before, immediately after, on the 17th day (mid of treatment), and at the end of CCRT, whereas 20 patients were taken as normal healthy controls and were not exposed to CCRT. The smears were stained with hematoxylin and eosin and Papanicolaou stain. SPSS version 20 (Armonk, NY: IBM Corp.) was used for statistical analysis and p > 0.05 was considered to be significant. Results CCRT-induced oral epithelial atypical cytological changes were predominantly noted at end of therapy (19.7%) in the contralateral normal buccal mucosa. Nuclear atypia features were higher on the 17th day and end of treatment; whereas, epithelial atypia was mainly observed on the 17th day of CCRT (40%). A highly significant association was observed between epithelial atypia and radio-chemotherapy dose (p = 0.045), between CCRT-induced epithelial atypical cytological changes and days of treatment (p = 0.001), and between days of CCRT and nuclear atypia (0.000) accordingly. Atypia was not observed in any control group. Conclusion Varying degrees of oral epithelial atypical cytological changes may occur in otherwise normal contralateral mucosa of the patients receiving CCRT.

Case Report: Hidden Oral Squamous Cell Carcinoma in Oral Somatic Symptom Disorder

Background: Burning mouth syndrome (BMS) is a common condition of predominant oral pain without evident cause, that maxillofacial surgeons and otolaryngologists often refer to psychiatrists as somatic symptom disorder. In very rare cases, its typical burning symptom mimics those of other diseases in which serious fatal comorbidities may be missed. We encountered three rare cases of oral squamous cell carcinoma (OSCC) with the first symptom of burning tongue. Case Presentation: Case 1: A 68-year-old woman had burning pain on the left lingual margin for 8 years. Antidepressant treatment was not efficacious. Cytology and biopsy revealed OSCC. Case 2: A 70-year-old man had burning sensation and paralysis of the tongue for 6 months. Magnetic resonance imaging (MRI) revealed a 37 × 23-mm mass under the floor of the mouth and enlargement of lymph nodes on both sides. Case 3: A 90-year-old man had burning sensation of the tongue for 1 year. MRI revealed a 12 × 12-mm mass on the mandible with bone absorption. Conclusion: This case series suggests that psychiatrists must always be careful in regarding BMS as somatic symptom disorder and be cautious of the possibility of OSCC, especially in elderly patients.

Nuclear F-actin Cytology in Oral Epithelial Dysplasia and Oral Squamous Cell Carcinoma

Oral cavity cancer has a low 5-y survival rate, but outcomes improve when the disease is detected early. Cytology is a less invasive method to assess oral potentially malignant disorders relative to the gold-standard scalpel biopsy and histopathology. In this report, we aimed to determine the utility of cytological signatures, including nuclear F-actin cell phenotypes, for classifying the entire spectrum of oral epithelial dysplasia and oral squamous cell carcinoma. We enrolled subjects with oral potentially malignant disorders, subjects with previously diagnosed malignant lesions, and healthy volunteers without lesions and obtained brush cytology specimens and matched scalpel biopsies from 486 subjects. Histopathological assessment of the scalpel biopsy specimens classified lesions into 6 categories. Brush cytology specimens were analyzed by machine learning classifiers trained to identify relevant cytological features. Multimodal diagnostic models were developed using cytology results, lesion characteristics, and risk factors. Squamous cells with nuclear F-actin staining were associated with early disease (i.e., lower proportions in benign lesions than in more severe lesions), whereas small round parabasal-like cells and leukocytes were associated with late disease (i.e., higher proportions in severe dysplasia and carcinoma than in less severe lesions). Lesions with the impression of oral lichen planus were unlikely to be either dysplastic or malignant. Cytological features substantially improved upon lesion appearance and risk factors in predicting squamous cell carcinoma. Diagnostic models accurately discriminated early and late disease with AUCs (95% CI) of 0.82 (0.77 to 0.87) and 0.93 (0.88 to 0.97), respectively. The cytological features identified here have the potential to improve screening and surveillance of the entire spectrum of oral potentially malignant disorders in multiple care settings.

A pilot study for early detection of oral premalignant diseases using oral cytology and Raman micro-spectroscopy: Assessment of confounding factors

This study demonstrates the efficacy of Raman micro-spectroscopy of oral cytological samples for differentiating dysplastic, potentially malignant lesions from those of normal, healthy donors. Cells were collected using brush biopsy from healthy donors (n = 20) and patients attending a Dysplasia Clinic (n = 20). Donors were sampled at four different sites (buccal mucosa, tongue, alveolus, gingiva), to ensure matched normal sites for all lesions, while patient samples were taken from clinically evident, histologically verified dysplastic lesions. Spectra were acquired from the nucleus and cytoplasm of individual cells of all samples and subjected to partial least squares-discriminant analysis. Discriminative sensitivities of 94% and 86% and specificity of 85% were achieved for the cytoplasm and nucleus, respectively, largely based on lipidic contributions of dysplastic cells. Alveolar/gingival samples were differentiated from tongue/buccal samples, indicating that anatomical site is potentially a confounding factor, while age, gender, smoking and alcohol consumption were confirmed not to be.

Optimized liquid-based cytology for the cellular and molecular analysis of oral keratinocytes: A promising diagnostic tool

BACKGROUND

Liquid-based cytology (LBC) has improved exfoliative cytology by facilitating the extraction of more precise information from epithelial cells. The aim of this study was to optimize a protocol using a conventional cytobrush to perform LBC, obtaining oral keratinocytes for their further cellular and molecular analysis.

METHODS

LBC was performed in 30 healthy donors from buccal mucosa. We evaluated the use of diethyl pyrocarbonate (DEPC)-treated Dulbecco's Modified Eagle Medium (DMEM) medium right after the collection of the cells. Cell morphology and viability were determined by Orcein staining and flow cytometry, respectively. RNA was extracted by the trizol method, and evaluated with spectrometry and electrophoresis. Finally, RNA was copied into cDNA and GAPDH and TLR2 genes were amplified by reverse transcription polymerase chain reaction (RT-PCR) and quantitative reverse transcription polymerase chain reaction (RT-qPCR) using specific primers.

RESULTS

Only DEPC-treated DMEM preserved the viability of intact intraepithelial keratinocytes. RNA quantity and quality improves in samples treated with DEPC. RNA integrity is comparable with a cell line control. GAPDH gene was successfully amplified by RT-PCR and RT-qPCR.

CONCLUSIONS

Therefore, LBC performed under these conditions becomes a reproducible technique for the retrieval of intraepithelial oral keratinocytes with good cell viability for cytomorphometric analysis, and extraction of good RNA quality suitable for molecular analyses such as PCR. We propose this LBC protocol as a complementary method to the cellular and molecular study of oral mucosa pathologies; however, it requires further study.

A systematic scoping review on utility of cytomorphometry in the detection of dysplasia in oral potentially malignant disorders

Background

Oral exfoliative cytology is simple, non-invasive, inexpensive tools prone to subjective bias. Objective computer-based quantitative cytomorphometry technique was developed in last few decades to overcome its limitation. However, there is no consensus about the utility of cytomorphometry as a routine screening tool for early detection of dysplastic changes.

Objectives

To review the utility of cytomorphometry in OPMDs in the detection of dysplasia changes.

Method

A scoping review was undertaken focusing on cytomorphometric analysis in exfoliative cells for detection of oral epithelial dysplasia and cytomorphometric parameter denoting dysplasia. The systematic search was carried out in the online journal databases (Scopus, Google Scholar, PubMed, Web of Science) using keywords until December 2019 for the studies evaluated the cytomorphometry in the detection of dysplastic changes in OPMDs. Three authors independently extracted data using collection forms.

Result

The search strategy found seven analytical cross-sectional studies for scoping review after eliminating 8940 out of 8947 initial results. The scoping review showed that cytomorphometry is useful tool in detecting the dysplastic changes in OPMDs. In addition, decrease in mean cellular area, increase in mean nuclear area, and decrease in mean cell diameter, increase mean nuclear diameter, increase in mean nuclear and cytoplasmic area ratio, associated with development of dysplastic changes in OPMDs.

Conclusion

Cytomorphometry is promising tool, yet there is currently no-good evidence to support role of cytomorphometry in detecting the dysplastic changes in OPMDs in this setting. More research is required for refinement of cytomorphometry as a screening tool.

Establishing the accuracy of a new and cheaper sample collection tool: Oral cytology versus oral histopathology

Objective:

High cost of tools used for the collection of oral cytology sample; deters their use as mass screening tool in the developing countries. Hence, this study aims to assess the diagnostic accuracy of a new, cheaper sample collection tool in the field of oral exfoliative cytology through comparison with histopathology.

Materials and Methods:

Fifty-seven patients out of 394 cases were selected for the study in whom the cytological examination was performed using the wooden end of a sterile cotton swab followed by biopsy. The cytological smear classified in accordance with the Pap classification was compared with the histopathological diagnosis.

Results:

The study recruited 11 cases of oral potentially malignant disorders, 33 cases of oral carcinomas, and 13 cases of other lesions. The sensitivity and specificity of the cytology test using the wooden end of a sterile cotton swab was 75.0% and 61.5%, respectively. The Spearman's correlation coefficient was 0.618, with the P < 0.01.

Conclusion:

Our study proves that the use of wooden end of a sterile cotton swab stick offers a low cost and fairly effective solution which is not only easily available but can be potentially applied as a mass screening tool at primary health-care centers.

V. A, Rana MH, Gurpur P, Skandarajah A, D’Ambrosio M, Ramanjinappa RD, Mohan SP, Raghavan N, Kandasarma U, N. S, Raghavan S, Hedne N, Koch F, Fletcher DA, Selvam S, Kollegal M, N. PB, Ladic L, Suresh A, Pandya HJ, Kuriakose MA. A smart tele-cytology point-of-care platform for oral cancer screening

Early detection of oral cancer necessitates a minimally invasive, tissue-specific diagnostic tool that facilitates screening/surveillance. Brush biopsy, though minimally invasive, demands skilled cyto-pathologist expertise. In this study, we explored the clinical utility/efficacy of a tele-cytology system in combination with Artificial Neural Network (ANN) based risk-stratification model for early detection of oral potentially malignant (OPML)/malignant lesion. A portable, automated tablet-based tele-cytology platform capable of digitization of cytology slides was evaluated for its efficacy in the detection of OPML/malignant lesions (n = 82) in comparison with conventional cytology and histology. Then, an image pre-processing algorithm was established to segregate cells, ANN was trained with images (n = 11,981) and a risk-stratification model developed. The specificity, sensitivity and accuracy of platform/ stratification model were computed, and agreement was examined using Kappa statistics. The tele-cytology platform, Cellscope, showed an overall accuracy of 84–86% with no difference between tele-cytology and conventional cytology in detection of oral lesions (kappa, 0.67–0.72). However, OPML could be detected with low sensitivity (18%) in accordance with the limitations of conventional cytology. The integration of image processing and development of an ANN-based risk stratification model improved the detection sensitivity of malignant lesions (93%) and high grade OPML (73%), thereby increasing the overall accuracy by 30%. Tele-cytology integrated with the risk stratification model, a novel strategy established in this study, can be an invaluable Point-of-Care (PoC) tool for early detection/screening in oral cancer. This study hence establishes the applicability of tele-cytology for accurate, remote diagnosis and use of automated ANN-based analysis in improving its efficacy.

Comparison of the Efficacy of Sediment Cytology over Oral Brush Cytology in Oral Leukoplakia

INTRODUCTION

A method called sediment cytology includes the investigation of smears arranged from the sediment of the biopsy specimen fixatives. The sediment from this fixative is used to prepare smears and provides a potentially rich source for cytological material. Investigation of the fixative sediment and understanding of the cytological picture with pertinent clinical and radiological information permits diagnosis in a few hours.

AIM

To evaluate the diagnostic efficacy of sediment cytology and oral brush cytology compared with histopathological findings in oral leukoplakia (OL) cases.

METHODS

Cytological smears were obtained from 30 clinically diagnosed OL lesions using 2 techniques: oral cytobrush and 10% formalin fixative sedimentation. Both smears were stained with Papanicolaou. Cytological smear evaluation was conducted with respect to cellularity, cell distribution, cellular clumping, and the presence of blood, debris, inflammatory cells, and microbial colonies. The cytopathological scores for all cases were compared between sediment and brush cytology and correlated with the histopathological diagnosis. For statistical analysis, the κ test and the Wilcoxon matched-pair test were used.

RESULTS

The cytobrush technique had a sensitivity of 83.3% for OL cases histopathologically diagnosed as severe dysplasia, while the sediment cytology technique had a sensitivity of 16.6%. For moderate/mild dysplasia cases, the cytobrush technique had a sensitivity of 7.7%, whereas the sediment technique showed no diagnostic sensitivity.

CONCLUSION

Based on the results from the present study, sediment cytology, unlike oral brush cytology, is not a useful screening tool for the preliminary diagnosis of potentially malignant oral lesions.

Development of a cytology-based multivariate analytical risk index for oral cancer

OBJECTIVES

The diagnosis and management of oral cavity cancers are often complicated by the uncertainty of which patients will undergo malignant transformation, obligating close surveillance over time. However, serial biopsies are undesirable, highly invasive, and subject to inherent issues with poor inter-pathologist agreement and unpredictability as a surrogate for malignant transformation and clinical outcomes. The goal of this study was to develop and evaluate a Multivariate Analytical Risk Index for Oral Cancer (MARIO) with potential to provide non-invasive, sensitive, and quantitative risk assessments for monitoring lesion progression.

MATERIALS AND METHODS

A series of predictive models were developed and validated using previously recorded single-cell data from oral cytology samples resulting in a "continuous risk score". Model development consisted of: (1) training base classification models for each diagnostic class pair, (2) pairwise coupling to obtain diagnostic class probabilities, and (3) a weighted aggregation resulting in a continuous MARIO.

RESULTS AND CONCLUSIONS

Diagnostic accuracy based on optimized cut-points for the test dataset ranged from 76.0% for Benign, to 82.4% for Dysplastic, 89.6% for Malignant, and 97.6% for Normal controls for an overall MARIO accuracy of 72.8%. Furthermore, a strong positive relationship with diagnostic severity was demonstrated (Pearson's coefficient = 0.805 for test dataset) as well as the ability of the MARIO to respond to subtle changes in cell composition. The development of a continuous MARIO for PMOL is presented, resulting in a sensitive, accurate, and non-invasive method with potential for enabling monitoring disease progression, recurrence, and the need for therapeutic intervention of these lesions.

Current Practice and Emerging Molecular Imaging Technologies in Oral Cancer Screening

Oral cancer is one of the most common cancers globally. Survival rates for patients are directly correlated with stage of diagnosis; despite this knowledge, 60% of individuals are presenting with late-stage disease. Currently, the initial evaluation of a questionable lesion is performed by a conventional visual examination with white light. If a lesion is deemed suspicious, a biopsy is taken for diagnosis. However, not all lesions present suspicious under visual white light examination, and there is limited specificity in differentiating between benign and malignant transformations. Several vital dyes, light-based detection systems, and cytology evaluation methods have been formulated to aid in the visualization process, but their lack of specific biomarkers resulted in high false-positive rates and thus limits their reliability as screening and guidance tools. In this review, we will analyze the current methodologies and demonstrate the need for specific intraoral imaging agents to aid in screening and diagnosis to identify patients earlier. Several novel molecular imaging agents will be presented as, by result of their molecular targeting, they aim to have high specificity for tumor pathways and can support in identifying dysplastic/cancerous lesions and guiding visualization of biopsy sites. Imaging agents that are easy to use, inexpensive, noninvasive, and specific can be utilized to increase the number of patients who are screened and monitored in a variety of different environments, with the ultimate goal of increasing early detection.

Management update of potentially premalignant oral epithelial lesions

The term oral potentially malignant disorders, proposed at the World Health Organization workshop in 2005, has now been renamed potentially premalignant oral epithelial lesions (PPOELs). It is important to differentiate among PPOELs, which is a broad term to define a wide variety of clinical lesions, and oral epithelial dysplasia, which should be reserved specifically for lesions with biopsy-proven foci of dysplasia. PPOELs encompass lesions that include leukoplakia, erythroplakia, erythroleukoplakia, lichen planus, and oral submucous fibrosis. The primary goal of management of dysplasia includes prevention, early detection, and treatment before malignant transformation. The aim of this article is to inform the clinician about management of PPOELs.

Feasibility of desorption electrospray ionization mass spectrometry for diagnosis of oral tongue squamous cell carcinoma

RATIONALE

Desorption electrospray ionization mass spectrometry (DESI-MS) has demonstrated utility in differentiating tumor from adjacent normal tissue in both urologic and neurosurgical specimens. We sought to evaluate if this technique had similar accuracy in differentiating oral tongue squamous cell carcinoma (SCC) from adjacent normal epithelium due to current issues with late diagnosis of SCC in advanced stages.

METHODS

Fresh frozen samples of SCC and adjacent normal tissue were obtained by surgical resection. Resections were analyzed using DESI-MS sometimes by a blinded technologist. Normative spectra were obtained for separate regions containing SCC or adjacent normal epithelium. Principal Component Analysis and Linear Discriminant Analysis (PCA-LDA) of spectra were used to predict SCC versus normal tongue epithelium. Predictions were compared with pathology to assess accuracy in differentiating oral SCC from adjacent normal tissue.

RESULTS

Initial PCA score and loading plots showed clear separation of SCC and normal epithelial tissue using DESI-MS. PCA-LDA resulted in accuracy rates of 95% for SCC versus normal and 93% for SCC, adjacent normal and normal. Additional samples were blindly analyzed with PCA-LDA pixel-by-pixel predicted classifications as SCC or normal tongue epithelial tissue and compared against histopathology. The m/z 700-900 prediction model showed a 91% accuracy rate.

CONCLUSIONS

DESI-MS accurately differentiated oral SCC from adjacent normal epithelium. Classification of all typical tissue types and pixel predictions with additional classifications should increase confidence in the validation model.

Improvization of conventional cytology by centrifuged liquid-based cytology in oral exfoliative cytology specimen

BACKGROUND

Exfoliative cytology is the microscopic examination of shed or desquamated cells from the epithelial surface. Centrifuged liquid-based cytology (CLBC) is a modified technique that was used in the current study.

AIMS

To compare the efficacy of CLBC with conventional cytology in apparently normal mucosa after staining with Papanicolaou (PAP) stain.

MATERIALS AND METHODS

Fifty cases of apparently normal mucosa from healthy subjects were selected for the study. The first sample was taken and spread on the slide by the conventional technique. The second sample was flushed out in a suspending solution, centrifuged, and the cell pellet obtained was used to make the smear. The stained smears were compared for seven parameters such as adequate cellularity, clear background, uniform distribution, cellular overlapping, cellular elongation, mucus, and inflammatory cells. Chi-square test was used for statistical analysis and P ≤ 0.05 was considered to be statistically significant.

RESULTS

There was a statistically significant difference between CLBC and conventional cytology with parameters such as adequate cellularity (P = 0.001), clear background (P = 0.001), uniform distribution (0.005), cellular overlapping, and cellular elongation (P = 0). The presence of mucus and inflammatory cells was minimal as the samples were collected from healthy subjects.

CONCLUSION

CLBC has better efficacy over the conventional method in all the parameters analyzed.

The prognostic value of GLUT-1 staining in the detection of malignant transformation in oral mucosa

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) ranks as the sixth most common tumor entity worldwide. Unfortunately, the multimodal treatment consisting of surgery, radiation, and chemotherapy does not show the desired efficacy. The intent of this study was to evaluate the sensitivity and specificity of an oral brush biopsy in combination with glucose transporter (GLUT)-1 staining in identifying premalignant and malignant lesions.

METHODS

A total of 72 patients were included in the study, divided into four diagnostic subgroups (24 healthy, 15 carcinoma, 18 leukoplakia, 15 oral lichen planus). Oral brush biopsies were taken and analyzed for GLUT-1 expression by immunocytologic staining. Incisional biopsy served as the gold standard.

RESULTS

Twelve (80 %) of the 15 carcinomas, nine (50 %) of the 18 leukoplakia, nine (60 %) of the 15 oral lichen planus, and none of the healthy specimens stained positive for GLUT-1. This resulted in a sensitivity rate of 80 % and a specificity rate of 68.42 %. Diagnostic accuracy was 70.83 % based on the correct diagnoses in 51 of 72 patients.

CONCLUSION

An oral brush biopsy can easily be performed throughout the entire oral cavity, is noninvasive, and shows high sensitivity and specificity rates with conventional cytology or computer-assisted analysis.

CLINICAL RELEVANCE

The significance of GLUT-1-specific staining with an oral brush biopsy is more limited than expected but could be used as an additional tool in detecting malignant transformation in the oral cavity.

'Cytology-on-a-chip' based sensors for monitoring of potentially malignant oral lesions

Despite significant advances in surgical procedures and treatment, long-term prognosis for patients with oral cancer remains poor, with survival rates among the lowest of major cancers. Better methods are desperately needed to identify potential malignancies early when treatments are more effective.

OBJECTIVE

To develop robust classification models from cytology-on-a-chip measurements that mirror diagnostic performance of gold standard approach involving tissue biopsy.

MATERIALS AND METHODS

Measurements were recorded from 714 prospectively recruited patients with suspicious lesions across 6 diagnostic categories (each confirmed by tissue biopsy -histopathology) using a powerful new 'cytology-on-a-chip' approach capable of executing high content analysis at a single cell level. Over 200 cellular features related to biomarker expression, nuclear parameters and cellular morphology were recorded per cell. By cataloging an average of 2000 cells per patient, these efforts resulted in nearly 13 million indexed objects.

RESULTS

Binary "low-risk"/"high-risk" models yielded AUC values of 0.88 and 0.84 for training and validation models, respectively, with an accompanying difference in sensitivity+specificity of 6.2%. In terms of accuracy, this model accurately predicted the correct diagnosis approximately 70% of the time, compared to the 69% initial agreement rate of the pool of expert pathologists. Key parameters identified in these models included cell circularity, Ki67 and EGFR expression, nuclear-cytoplasmic ratio, nuclear area, and cell area.

CONCLUSIONS

This chip-based approach yields objective data that can be leveraged for diagnosis and management of patients with PMOL as well as uncovering new molecular-level insights behind cytological differences across the OED spectrum.

Evaluation of brush cytology and DNA image cytometry for the detection of cancer of the oral cavity

BACKGROUND

Cancer of the oral cavity is the sixth most common malignancy reported worldwide. This study was undertaken to evaluate the efficacy of brush cytology and the adjunctive role of DNA image cytometry (ICM) in the diagnosis of oral cancer.

METHOD

Oral brush smears and biopsy were obtained from 100 consecutive patients presenting with suspicious oral lesions. DNA-ICM was performed on 96 cytology smears which had adequate cellularity.

RESULTS

On cytology, 54 cases were benign, 36 were malignant, 6 were suspicious for malignancy, and 4 were inadequate due to scanty cellularity. On histopathologic examination, 49 cases were diagnosed as squamous cell carcinoma and 51 cases as benign. The sensitivity of brush cytology for the detection of cancer was 83.3% and the specificity was 95.8%. The positive and negative predictive values were 95.2% and 85.2%, respectively, with a diagnostic accuracy of 86%. Out of 96 cases analyzed by image analysis to assess DNA ploidy, 33 cases were aneuploid and 63 were diploid. The sensitivity, specificity, positive predictive value, and negative predictive value of DNA-ICM were 68.7%, 100%, 100%, and 76.1%, respectively, giving a diagnostic accuracy of 81%. The combination of cytology and DNA cytometry increased the sensitivity to 92% and specificity to 100%.

CONCLUSION

The study demonstrates the usefulness of DNA-ICM as an adjunct to brush cytology to diagnose oral cancer. It reduces the false negative cases on cytology and also adds to objectivity in cytologically doubtful cases.

Clinico-epidemiological study of oral squamous cell carcinoma: A tertiary care centre study in North India

INTRODUCTION

Oral squamous cell carcinoma (OSCC) ranks 12th most common cancer in the world.

OBJECTIVE

The aim of this study was to retrospectively evaluate the OSCC.

METHODS

A retrospective study of 611 OSCC patients from January 2010 to December 2013 was carried out in Department of Surgical Oncology, King George's Medical University, Lucknow, India. Details of patient's sex, age, tobacco habit and site of cancer were noted. Data were analyzed by Student's t test and chi-squire (χ (2)) test.

RESULTS

The prevalence of OSCC was significantly (p < 0.001) higher in males (75.9%) than females (24.1%). The mean age of female patients was higher than males (p < 0.001). In both the genders, the buccal mucosa and gingivobuccal sulcus were found to be the most affected sites. Moreover, the smokeless form of tobacco was found to be significantly associated with OSCC, especially in females.

CONCLUSION

The study concluded that OSCC is more common in men as compared to women, probably due to habit of tobacco consumption. Smokeless tobacco use is an important risk factor, especially in females.

Meta-analysis of two computer-assisted screening methods for diagnosing oral precancer and cancer

The early diagnosis of oral precancer and cancer is crucial and could have the highest impact on improving survival rates. A meta-analysis was conducted to compare the accuracy between the OralCDx brush biopsy and DNA-image cytometry in diagnosing both conditions. Bibliographic databases were systematically searched for original relevant studies on the early diagnosis of oral precancer and oral cancer. Study characteristics were evaluated to determine the accuracy of the two screening strategies. Thirteen studies (eight of OralCDx brush biopsy and five of DNA-image cytometry) were identified as having reported on 1981 oral mucosa lesions. The meta-analysis found that the area under the summary receiver operating characteristic curves of the OralCDx brush biopsy and DNA-image cytometry were 0.8879 and 0.9885, respectively. The pooled sensitivity, specificity, and diagnostic odds ratio of the OralCDx brush biopsy were 86% (95% CI 81-90), 81% (95% CI 78-85), and 20.36 (95% CI 2.72-152.67), respectively, while these modalities of DNA-image cytometry were 89% (95% CI 83-94), 99% (95% CI 97-100), and 446.08 (95% CI 73.36-2712.43), respectively. Results of a pairwise comparison between each modality demonstrated that specificity, area under the curve (AUC), and Q(∗) index of DNA-image cytometry was significantly higher than that of the OralCDx brush biopsy (Z=2.821, p<0.05; Z=1.711, p<0.05; Z=1.727, p<0.05), but no significant difference in sensitivity was found (Z=1.520, p>0.05). In conclusion, the meta-analysis of the published studies indicated that DNA-image cytometry is more accurate than the OralCDx brush biopsy in diagnosing oral precancer and oral cancer.

Efficacy of Oral Brush Biopsy without Computer-Assisted Analysis in Oral Premalignant and Malignant Lesions: A Study

BACKGROUND

In the present study, the reliability of oral brush biopsy in identifying dysplasia in clinically diagnosed oral potentially malignant and malignant lesions was evaluated while comparing the findings with scalpel biopsy in terms of sensitivity and specificity.

MATERIALS AND METHODS

In our study, a total number of 50 patients that included both premalignant and malignant lesions were included. Oral brush cytology using a cytobrush was done for all patients, which was followed by incisional biopsy. Sensitivity, specificity, positive and negative predictive values were obtained. To see the agreement between two modalities Kappa test of agreement was applied. A P < 0.05 was considered to indicate statistical significance. Proportions were compared using Chi-square or Fisher's exact test.

RESULTS

Brush cytology using a cytobrush is a reliable adjunct to histopathology in detecting oral premalignant and malignant oral lesions and can be easily performed with less cost and less discomfort. This technique showed a reasonable sensitivity and specificity thus substantiating its reliability in evaluation of oral premalignant and malignant lesions.

CONCLUSION

The oral brush biopsy is a simple and rapid, non-invasive and relatively painless and well accepted by patient. It is suitable in population screening programs and for pre- and post-treatment observation of confirmed premalignant and malignant lesions and has proved applications in incapacitated areas.

Diagnostic modalities for squamous cell carcinoma: an extensive review of literature-considering toluidine blue as a useful adjunct

INTRODUCTION

Oral Squamous Cell Carcinomas have been considered as the most prevalent malignancies in the head and neck region and are frequently undiagnosed until symptomatic with an advanced stage of disease. So there is an urgent need to device methods for the detection of oral premalignant lesions and oral cancer at an early stage in order to improve the survival rate for patients. A number of tests have been done for the detection of oral cancer which include oral brush biopsy, the Vizilite, oral autofluorescence including chemiluscence, photodynamic detection, toluidine blue staining, methylene blue staining, incisional biopsy and many more.

MATERIAL

The article reviews various diagnostic modalities available at present for detection of squamous cell carcinomas and oral epithelial dysplasias based on advanced PUBMED search of the English language literature from the year 1972 to present in order to help us select the most suitable among them fulfilling the desired criteria of being non-invasive, highly specific and sensitive, economically viable, having a scope to be used for mass screening, easy to process, having low inter examiner variability and possibly not requiring high expertise to conduct and interpret the results.

CONCLUSION

After reviewing various diagnostic modalities, we conclude that toluidine blue staining emerges as a clear winner among all these and it can act as a valuable adjunct to incisional biopsy in detection of oral cancer and may not substitute it except in certain circumstances when its results are carefully correlated with the patient history and clinical characteristics of the mucosal disorder, considering the fact that incisional biopsy has been reported to cause dissemination of cancer cells in the circulation there by increasing the possibility of metastasis. We must emphasize that toludine blue is a screening modality and not a diagnostic procedure like biopsy and hence cannot replace a confirmatory biopsy as a whole.

Cytomorphometric analysis of oral buccal mucosal smears in tobacco and arecanut chewers who abused with and without betel leaf

BACKGROUND

Tobacco in any form (smoking or chewing), arecanut chewing, and alcohol are considered to be the major extrinsic etiological factors for potentially malignant disorders of the oral cavity and for squamous cell carcinoma, the most common oral malignancy in India. An increase in nuclear diameter (ND) and nucleus-cell ratio (NCR) with a reduction in cell diameter (CD) are early cytological indicators of dysplastic change. The authors sought to identify cytomorphometric changes in ND, CD, and NCR of oral buccal cells in tobacco and arecanut chewers who chewed with or without betel leaf.

METHODS

Participants represented 3 groups. Group I consisted of 30 individuals who chewed tobacco and arecanut with betel leaf (BQT chewers). Group II consisted of 30 individuals who chewed tobacco and arecanut without betel leaf (Gutka chewers). Group III comprised 30 apparently healthy nonabusers. Cytological smears were prepared and stained with modified-Papanicolaou stain.

RESULTS

Comparisons between Groups I and II and Groups II and III showed that ND was increased, with P values of .054 and .008, respectively, whereas a comparison of Groups I and III showed no statistical significance. Comparisons between Groups I and II and Groups II and III showed that CD was statistically reduced, with P values of .037 and <.000, respectively, whereas comparison of Groups I and III showed no statistical significance. Comparisons between Groups I and II and groups II and III showed that NCR was statistically increased, with P values of <.000, whereas a comparison of Groups I and III showed no statistical significance.

CONCLUSIONS

CD, ND, and NCR showed statistically significant changes in Group II in comparison with Group I, which could indicate larger and earlier risk of carcinoma for Gutka chewers than in BQT chewers.