The impact of liquid-based oral cytology on the diagnosis of oral squamous dysplasia and carcinoma

OBJECTIVE: Even though diagnostic oral exfoliative cytology is a useful, economical and practical tool in the diagnosis of oral dysplasia and carcinoma, it is not yet extensively used. The results of conventional exfoliative and liquid-based diagnostic cytology in oral potentially malignant lesions (PML) are herein reported and compared with the histological diagnosis. METHODS: Either conventional (89) or liquid-based (384) exfoliative cytology was used for the diagnosis of oral dysplasia/carcinoma in 473 subjects and the results were compared with scalpel biopsy histology. Cells were collected using a Cytobrush device for conventional smears and with a dermatological curette for the liquid-based cytology. The 'curette technique' also allowed for the collection of 'accidental' tissue fragments, utilized as microbiopsies. RESULTS: Histological diagnosis was squamous carcinoma in 96 of 473 cases, high-grade dysplasia (oral intraepithelial neoplasia two to three) in 24 and other lesions in 353 cases. The smears in the conventional cytology group were inadequate in 12.4%, with an 85.7% sensitivity and a 95.9% specificity. There were 8.8% of inadequate specimens in the liquid-based cytology group; sensitivity was 95.1% and specificity was 99.0%. CONCLUSIONS: Although conventional cytology is useful when diagnosing oral PML (better sensitivity and predictive positive value if compared with the cervical smear test with similar specificity) and can improve the accuracy of histological diagnosis, liquid-based cytology gives better results, as it not only enhances both sensitivity and specificity, but also provides material for further investigation (AgNORs, DNA, microbiopsies, etc.).     

Laminin-5 immunocytochemistry: a new tool for identifying dysplastic cells in oral brush biopsies

BACKGROUND: The brush biopsy technique is not only a seminal technique but also a critically discussed method for detection of oral pre-cancerous stages and manifest carcinomas. The gamma2 chain of laminin-5 and its proteolytic fragments comprise an invasion factor for many carcinomas. OBJECTIVES: The aim of this study was to determine whether the immunocytochemical presentation of the laminin gamma2 chain identifies pre-invasive or invasive squamous cells in brush biopsies. METHODS: The value-based identification of atypical epithelia was analysed in 93 consecutive brush biopsies with histopathological diagnoses: standardized haematoxylin and eosin staining; standardized immunocytochemistry: monoclonal antibodies against laminin gamma2 chain: D4B5, 4G1, detection using ChemMate and Autostainer. RESULTS: Conventional cytology did not result in any false-positive cases, i.e. atypical cells in normal, inflamed or benignly hyperproliferative mucosa (specificity, 100%), whereas immunocytochemistry revealed one false-positive case (specificity, 98%). In brush biopsies of oral squamous cell carcinomas, the following immunocytochemical patterns were possible: (1) staining of the cytoplasm, (2) banded markings between clumped carcinoma cells and (3) positive hazes surrounding atypical cells. Bacterial colonies appeared as false-positive results. Four of 27 carcinomas and one of three recurrences were not cytologically identified (sensitivity of conventional cytology, 79%). Three of the five carcinomas not identified by cytology were immunocytochemically stained with laminin gamma2 chain antibody (sensitivity of laminin gamma2 chain immunocytochemistry, 93%). The positive predictive value was 100% for conventional cytology and 97% for laminin gamma2 chain immunocytochemistry. The negative predictive value attained was 92% for conventional cytology and 97% for laminin gamma2 chain immunocytochemistry. CONCLUSIONS: The high sensitivity level observed for method-enhanced brush cytology suggests that this technique be used as an initial diagnostic step.     

Non-computer-assisted liquid-based cytology for diagnosis of oral squamous cell carcinoma

Abstract

The development of oral squamous cell carcinoma (OSCC) occasionally follows the neoplastic progression of other premalignant lesions. Although biopsy is the definitive diagnostic method, liquid-based cytology is an adequate method for screening suspicious lesions. We compared liquid-based cytology to histology for diagnosis of OSCC in patients with oral lesions that raised clinical suspicion of malignancy. Our sample consisted of 48 patients. Cytological samples were obtained by scraping the lesion superficially using Cytobrush^®. We conducted cytological and histopathological evaluation of all preparations. We estimated sensitivity and specificity levels as well as positive and negative predictive values. The degree of inter-observer agreement for both methods was assessed using the kappa index. Twenty-eight (58.3%) of the cases finally were diagnosed with OSCC and 20 (41.7%) were determined to be premalignant lesions. We observed eight false negatives and no false positives; OSCC prevalence was 56.5%. The values for diagnostic indices were: sensitivity, 69% (CI 95%, prevalence 51.87); specificity, 100%; positive predictive value, 100%; negative predictive value, 71% (CI 95% 54.82). A kappa index of 0.622 (CI 95% 0.93, 0.39) was observed.     

Cytological changes in oral mucosa in denture stomatitis

The cytological patterns associated with the atrophic and hyperplastic forms of denture stomatitis (DS) were studied in 94 patients with DS and 33 controls. Forty percent of patients with DS and 30% of patients in the control group had a positive culture for Candida. When compared to the smears from the control group patients, the smears from patients with DS presented a higher amount of: i) cytological cellular material; ii) fungal cells; iii) cells of the intermediate and parabasal types; iv) cells of the intermediate type with a positive culture for Candida; and v) polymorphonuclear leukocytes, preferentially in association with a positive culture for Candida. Conversely, smears from the control group showed a higher percentage of cells of the superficial type than those of the patients with DS. Although no specific changes in the DS-affected mucosa have been observed by cytology, we consider that this is a useful, easy and inexpensive technique that gives important information about the inflamed mucosa it can be used in the treatment and control of these patients.     

Micronuclei and other nuclear anomalies in normal human buccal mucosa cells of oral cancer patients undergoing radiotherapy: a field effect

We evaluated micronuclei and other nuclear anomalies in exfoliated epithelial cells of the oral cavity on the side opposite the lesion targeted by radiotherapy and correlated them with radiation doses. Buccal smears were obtained from oral cancer patients undergoing radiotherapy with a cumulative dose of at least 1000 rad for 3 weeks and from controls matched for age, gender and habits. The exfoliated cells from the mucosa were collected using a cytobrush; smears were prepared, fixed in 80% methanol and stained using the Feulgen plus fast green method. The mean number of micronuclei and other nuclear anomalies/1000 cells was significantly greater in patients undergoing radiotherapy treatment, but the differences were not significant compared to radiation doses. It appears that radiotherapy has a potent clastogenic effect on buccal mucosal cells of oral cancer patients.     

Induction of endonuclease G-mediated apopotosis in human oral squamous cell carcinoma cells by protein kinase C inhibitor safingol

PKC inhibitor safingol suppressed the growth of human oral squamous cell carcinoma (SCC) cells significantly at concentrations that inhibit PKC isoforms. Safingol inhibited the translocation of PKC following treatment with 12-o-tetradecanoylphorbol 13-acetate (TPA) in PKC α-EGFP-transfected cells, but not in PKC β-EGFP- transfected cells, indicating selective inhibition for PKC α in oral SCC cells. Flow cytometric analysis and DNA analysis by agarose gel electrophoresis revealed an increase in the proportion of sub-G₁ cells and DNA fragmentation in safingol-treated cells. Mitochondrial membrane potential was decreased, and cytochrome c was released from mitochondria. However, the safingol-induced cell death was not accompanied by activation of caspase 3 and cleavage of poly (ADP-ribose) polymerase (PARP). The broad-spectrum caspase inhibitor BD-fmk failed to prevent safingol-induced cell death. Another apoptogenic factor endonuclease G, but not apoptosis-inducing factor (AIF), was also released from mitochondria and translocated to the nucleus. These results suggest that PKC α inhibitor safingol induces an endonuclease G- mediated apoptosis in a caspase-independent manner.     

Cytopathology training in the United States – a personal view

In this review we present an outline of cytopathology training in the United States, for a non-US readership.     

LCK, survivin and PI-3K in the molecular biomarker profiling of oral lichen planus and oral squamous cell carcinoma

T cell signaling is critical in oral lichen planus (OLP) based on the pathogenesis of this chronic inflammatory autoimmune mucocutaneous lesion. Lck plays a key role in T cell signaling; ultimately this signaling affects other targets such as PI-3K. Excessive activity in PI-3K inhibits apoptosis and promotes uncontrolled cell growth. Molecular biomarker profiling in OLP, Chronic Interface Mucosities (CIM), Epithelial Dysplasia (EpD) and Oral Squamous Cell Carcinoma (SCCA) with application of the principle of biomarker voting may represent a new frontier in the diagnosis, assessment and the arguable debate of OLP transformation to cancer. The presence of Lck, PI-3K and Survivin, a cancer specific anti-apoptotic protein was assessed, using immunohistochemistry and tissue micro-array on patient samples, in OLP, SCCA, CIM and EpD. Lck expression was very high in 78.6 % of OLP patients compared to 3.7% in SCCA; PI-3K was high in 63% of SCCA, 100% of EpD, and 35.7% OLP cases. Survivin was high in 64.3% of OLP cases, 96.3% of SCCA, and 100% of EpD. CIM cases may be slightly different molecularly to OLP. Taken together, our data suggest that biomarker protein voting can be effectively used to isolate high-risk OLP cases. Specifically, we show data with four remarkable cases demonstrating that molecular factors are predictive of histopathology. We conclude that it is safer to treat OLP as premalignant lesions, to adopt aggressive treatment measure in histopathologic described well and moderately differentiated SCCA, and to monitor progress of these diseases molecularly using individualized auto-proteomic approach. The use of Lck inhibitors in OLP management needs to be investigated in the future.     

Tissue lipid peroxidation and glutathione‐dependent enzyme status in patients with oral squamous cell carcinoma

We examined the extent of lipid peroxidation and the status of reduced glutathione (GSH) and the GSH‐dependent enzymes—glutathione peroxidase (GPx) and glutathione‐S‐transferase (GST)—in oral tumour tissues from 33 adult oral cancer patients and an equal number of age‐ and sex‐matched normal subjects. Diminished lipid peroxidation in the oral tumour tissue was accompanied by a significant decrease in phospholipids and an increase in the cholesterol/phospholipid (C/P) ratio. The concentration of glutathione and the activities of GPx and GST were elevated in oral tumour tissues. These findings suggest that GSH‐ and GSH‐dependent enzymes play a crucial role in tobacco‐related tumourigenesis and may be considered as markers of carcinogen exposure. Copyright © 1999 John Wiley & Sons, Ltd.     

Two populations of TSPO binding sites in oral cancer SCC-15 cells

Oral cancer mortality and morbidity rates remain high. The main inducer of oral cancer is cigarette smoke (CS). Translocator protein 18 kDa (TSPO) was shown to play a role in carcinogenesis. We characterized TSPO binding sites in human oral cancer cell line SCC-15 and examined effect of CS on TSPO binding. We exposed SCC-15 human squamous cells to cigarette smoke. [³H]PK 11195 binding results were assessed in cells confluent for one day. To characterize the number of population sites, a custom written Matlab program compared Pearson linear correlation coefficients between all points in the Scatchard plot. Using [³H]PK 11195 as a radio ligand, we found that TSPO binding sites are not uniform, but separated into two sub-populations, one with high affinity (respective Kd and Bmax values of 1.40±0.08 nM and 1586±48 fmol/mg protein), another with lower affinity (respective Kd and Bmax values of 61±5 nM and 26260±1050 fmol/mg protein). We demonstrate rapid decrease in TSPO binding to the high affinity site induced by exposure to CS; specifically, significant 36% decrease in binding after 30 min CS exposure (p<0.05), and 69% decrease after 2 h CS exposure (p<0.05). Association between TSPO and CS exposure may contribute to understanding the underlying mechanism of oral carcinogenesis.     

Nuclear metabolic changes induced by tumor necrosis factor in Daudi lymphoma cells; a multiparametric analysis.

The effects of r-TNF alpha on cell cycle progression and DNA polymerase activity in Daudi lymphoma cells have been analyzed. Cytofluorimetric analysis of the cell cycle after 6 to 24 hr of treatment revealed both a decrease of BrdU incorporation per cell and a light inhibition of S phase as assessed by the analysis of the percentual distribution of cell cycle compartments. The reduction of BrdU incorporation can be related to the early decrease in the rate of DNA synthesis that follows r-TNF alpha treatment. These results suggest that one of the early events induced by r-TNF alpha at nuclear level is the slowering of DNA synthesis leading to a reduced cell cycle progression.     

Intraperitoneal free cancer cells in non‐gynaecological adenocarcinomas: a reproducibility study

E. Piaton, L. Villeneuve, C. Maurice, C. Paulin, M. Cottier, B. Fontanière, M. Salle, D. Seigneurin, S. Vancina, E. Decullier, F. N. Gilly and E. Cotte Intraperitoneal free cancer cells in non‐gynaecological adenocarcinomas: a reproducibility study Objective: In recent years, therapeutic approaches including cytoreductive surgery followed by intraperitoneal chemotherapy have proven effective in peritoneal carcinomatosis of colorectal origin. If cytology is to be used to include patients in aggressive treatment regimens, it is necessary to evaluate its performance, particularly in terms of specificity. The aim of this study was to assess interobserver agreement for the detection of intraperitoneal free cancer cells (IFCCs) in patients with non‐gynaecological adenocarcinomas. Methods: Over a 5‐year period, 1223 patients were recruited in 19 French surgery departments. Peritoneal samples were examined in 14 dispersed pathology laboratories. Giemsa‐stained slides were sent to a control reader blind to the previous diagnosis. Discordant cases, concordant positive results and a random selection of negative concordant cases were reviewed by a panel of seven cytopathologists. The ‘final diagnosis’ was that of the consensus meetings but took into account locally‐processed slides. Results: Gathering dubious cases with negative results, a 95.6% concordance was achieved between local readers and the control reader. IFCCs were ascertained by the panel in 85 cases (7.0%). Eight of 873 colorectal cancers cases viewed locally were falsely positive (0.9%). Radiotherapy and neoadjuvant therapy had no impact on the false‐positive rate as assessed by final validation by the panel (P > 0.05). Samples initially considered as dubious were reclassified as negative by the panel in 24 of 25 cases (96.0%). Conclusions: The panel consensus allowed reclassification of most dubious/equivocal peritoneal cytology cases, whereas clearcut distinction between benign and malignant cases was correctly achieved in almost all cases.     

Endometrial carcinoma in high‐risk populations: is it time to consider a screening policy?

Endometrial carcinoma (EC) is the leading female genital tract malignancy in industrialized countries. It will become an important public health problem in the coming years in the USA and Europe, where its incidence is increasing, and next‐generation interventions should include periodical screening in high‐risk women. In this review, we discuss the importance to gynaecologists of detecting women at high risk and offering an adequate screening programme. Screening for EC is particularly challenging and there is currently no proven programme for the surveillance of women estimated to be at an increased risk of developing this form of cancer. The data in the literature, including this and previous issues of Cytopathology, and personal experience suggest that endometrial liquid‐based cytology (LBC) might play an essential role in a screening policy for EC. LBC may enable practitioners to reduce age‐adjusted mortality for women at high risk for EC.     

Significance of bizarre cells in cervical screening liquid‐based cytology: A prospective study of 15 cases

Objective

The aim of this study was to assess the significance of bizarre cells (cells of squamous origin with a superficial squamous cell‐type cytoplasm and characterised by multinucleation that produces bizarre nuclear shapes) in liquid‐based cytology (LBC) Papanicoaou (pap) smears with clinical and histological follow‐up correlation.

Methods

Fifteen patients, all with LBC samples containing bizarre cells, were identified in routine ThinPrep^® LBC workload. HPV testing was performed in each case using residual LBC material. Cytological‐histological correlations were reviewed.

Results

All 15 LBC samples contained bizarre cells and tested positive for high‐risk HPV types. Ten of the 15 cases were identified as atypical squamous cells ‐ cannot exclude an HSIL (ASC‐H) with secondary diagnosis of low‐grade squamous intraepithelial lesion (LSIL), while five cases were identified as high‐grade squamous intraepithelial lesion (HSIL), and a subsequent biopsy was recommended. Additionally, 13/15 cases underwent cone biopsy or hysterectomy within 1‐11 months, of which 10 showed histologically confirmed HSIL end‐points. LSIL was present in three cases. Bizarre cells were identified in the HSIL epithelium of five cone biopsies.

Conclusions

Identification of bizarre cells in LBC is straightforward and may facilitate diagnosis. The cytology of bizarre cells is associated with HSIL in cone biopsies. We recommend assigning LBC samples containing bizarre cells as ASC‐H with secondary diagnosis of LSIL.     

Altered serum and salivary C-reactive protein levels in patients with oral premalignant lesions and oral squamous cell carcinoma

Chronic inflammation is associated with cancer development. C-reactive protein (CRP), an acute phase protein synthesized primarily in the liver, is a marker for inflammation and for the progression of many cancers. We compared serum and salivary CRP levels in 20 normal individuals, 20 patients with oral premalignant lesions and 20 patients with oral squamous cell carcinoma (OSCC) to assess its efficacy as a prognostic indicator for OSCC. Saliva and blood samples were obtained and evaluated for CRP levels. Mean CRP levels were higher in patients with oral premalignant lesions compared to controls. CRP levels in OSCC patients were elevated and were associated with advanced tumor stages.     

Relationship between human oral lichen planus and oral squamous cell carcinoma at a genomic level: a datamining study

The leader gene approach is a data mining method based on the systematic search for genes involved in a specific process and their ranking according to the number of interconnections with the other genes identified. The genes with the strongest interconnections are termed leader genes, since they may be supposed to play an important role in the process. The potential of malignant progression of OLP to oral squamous cell carcinoma (OSCC) is still not completely clear. In this study, the leader gene approach is applied to investigate the association between OLP and OSCC at a molecular level. Results were integrated with those obtained in an experimental analysis (see paper 1 of this series). Genes involved in OLP and OSCC were identified by systematic queries to dedicated databases. Interconnections among identified genes were calculated and given a confidence value using STRING database. Leader genes were identified by clustering genes according to their interconnections. This theoretical analysis shows that OLP and OSCC share two leader genes: TP53 and CDKN1A, involved in the PI3K signalling events mediated by AKT pathway. This finding and those obtained in the experimental analysis suggest the possible involvement of some key genes/proteins LCK, PIK3CA, BIRC5, TP53 and CDKN1A in the malignant progression from OLP to OSCC. Moreover, these findings support the role of some molecular pathways, namely IL2 signalling events mediated by PI3K, PI3K signalling events mediated by AKT, and, possibly, Aurora A signalling in the association between OLP and OSCC.