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Oral Cytology, Biopsy and Other Oral Cancer Diagnostics

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Oral Cytology, Biopsy and Other Oral Cancer Diagnostics Oral Cancer Diagnostics With oral cancer in order to achieve a good clinically outcome, early detection and ... – PowerPoint PPT presentation

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Title: Oral Cytology, Biopsy and Other Oral Cancer Diagnostics


1
Oral Cytology, Biopsy and Other Oral Cancer
Diagnostics
2
Oral Cancer Diagnostics
  • With oral cancer in order to achieve a good
    clinically outcome, early detection and adequate
    early treatment are absolutely necessary. As the
    size of the tumor and the extent of its spread
    increases, the chances for a good prognosis
    lessens expeditiously.
  • Biopsy is the only method of definitively
    diagnosing an oral cancer.
  • However, immediate biopsy of every ill-defined
    lesion may not be practical or in some cases
    indicated.

3
Oral Cytology
  • Exfoliative cytology has been used for decades as
    a simple, reliable and acceptable technique to
    support clinical judgment in helping
    differentiate benign and malignant lesions.
  • Many of the principles, concepts and techniques
    used in exfoliative cytology are applied to the
    newer technique of oral brush biopsy, which will
    be discussed later in this lecture.
  • However, exfoliative cytology (and brush biopsy)
    are adjuncts to not a substitute for biopsy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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