|Year : 2018 | Volume
| Issue : 5 | Page : 921-925
Comparative analysis of oral rinse-based cytology and conventional exfoliative cytology: A pilot study
Treville Pereira, Kashmira Kesarkar, Avinash Tamgadge, Sudhir Bhalerao, Subraj Shetty
Department of Oral and Maxillofacial Pathology and Microbiology, School of Dentistry, D. Y. Patil University, Nerul, Navi Mumbai, Maharashtra, India
|Date of Web Publication||7-Sep-2018|
Department of Oral and Maxillofacial Pathology and Microbiology, School of Dentistry, D. Y. Patil University, Sector 7, Nerul, Navi Mumbai - 400 706, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Oral exfoliative cytology is a novel technique of using cells to detect dysplastic changes in the oral cavity in potentially malignant disorders and malignant oral lesions in resourced challenged areas. The aim of this study was to compare specimen adequacy and cellular clarity between oral rinse-based smears and conventional smears in normal controls, histologically confirmed and clinically diagnosed squamous cell carcinoma, and oral leukoplakia. For many years, oral rinse-based cytology has been used to detect candidal colonization in microbiology. Emphasis has been placed to detect changes in oral rinse-based cytology. From this research and development, oral rinse-based cytology has evolved as a method of preparing samples for examination in cytopathology.
Materials and Methods: Oral exfoliated cells from 10 cases of smears of potentially malignant disorders (oral leukoplakia), 10 cases of histologically confirmed and clinically diagnosed squamous cell carcinoma, and 10 controls with healthy mucosa were taken. Smears were stained with the Papanicolaou stain and were examined independently by two different oral pathologists. The results were compared to assess four parameters such as nuclear cytoplasmic ratio, sample adequacy, cellular distribution, and cellular clarity in both the smears. The results were then analyzed with SPSS (version 20) software using the descriptive statistics such as mean and standard deviation and inferential statistics such as t-test and one-way ANOVA. The level of significance was set at 5%.
Results: Oral rinse-based cytology was significantly more efficient than conventional exfoliative cytology in terms of cellular clarity (P < 0.001), cellular distribution (P < 0.001), and sample adequacy (P < 0.001).
Conclusion: Oral rinse-based cytology shows overall improvement in cellular clarity, sample adequacy as compared to traditional exfoliative cytology.
Keywords: Conventional cytology, oral cancer, oral leukoplakia, oral rinse-based cytology
|How to cite this article:|
Pereira T, Kesarkar K, Tamgadge A, Bhalerao S, Shetty S. Comparative analysis of oral rinse-based cytology and conventional exfoliative cytology: A pilot study. J Can Res Ther 2018;14:921-5
|How to cite this URL:|
Pereira T, Kesarkar K, Tamgadge A, Bhalerao S, Shetty S. Comparative analysis of oral rinse-based cytology and conventional exfoliative cytology: A pilot study. J Can Res Ther [serial online] 2018 [cited 2019 Jan 16];14:921-5. Available from: http://www.cancerjournal.net/text.asp?2018/14/5/921/179095
| > Introduction|| |
Oral cancer is one of the important causes of mortality. Curbing and detecting this menace at the earliest is of primary concern to the health professionals. Oral cancer arises from preexisting lesions and conditions in majority of the cases. Primary prevention, early detection, and prompt treatment are the most acceptable policies in the control of oral cancer. Scalpel biopsy has been the gold standard for detecting oral premalignant and malignant lesions. Since scalpel biopsy is invasive, several other screening aids have been used to detect cancerous changes. Exfoliative cytology is one of the best methods for early diagnosis of cancer, which is a fast, safe, noninvasive, inexpensive, high sensitivity, and without need of anesthesia method. With advancements in cytologic techniques that have resulted in the development of liquid-based preparations, the use of this technique for the diagnosis of oral lesions has gained interest. Thus, a study was planned to assess the cells obtained from oral rinse-based smears and conventional smears in normal controls, histologically confirmed and clinically diagnosed squamous cell carcinoma, and oral leukoplakia.
| > Materials and Methods|| |
Thirty subjects from the Department of Oral and Maxillofacial Pathology were selected for the study. The study was approved by the Institutional Ethical Committee, and written informed consent was obtained from all the participants. The study comprised of 10 subjects with histologically confirmed oral squamous cell carcinoma, 10 subjects with clinically diagnosed oral leukoplakia, and 10 normal age- and sex-matched controls. None of the selected patients had started treatment and none presented with other neoplasia elsewhere. The oral leukoplakia subjects were chosen based on clinical examination alone. History and physical examinations were performed. The latter included careful examination of the oral cavity and was followed by exfoliative cytology (oral rinse-based technique followed by the conventional one). The oral rinse-based technique was used to collect oral cells. The patient was asked to swish his/her mouth with water and expectorate. Then, the suspected oral lesion was rubbed on firmly by the clinician or by the patient themselves using their tongue, in the accessible areas, for 30 s. When swishing phosphate buffered saline, pH 7.2 was used and the patient was asked to expectorate into a sterile container. Once the sample was obtained, it was labeled and centrifuged at 1000 rpm for 5 min. The supernatant fluid was discarded and a micropipette was used to collect the cells from the cell plug and smears were prepared. For exfoliative cytology, scrapings were obtained from a standard moistened wooden spatula. The scrapings were smeared on labeled glass slides. All the slides thus prepared were immediately fixed in absolute alcohol and consequently stained with a Papanicolaou stain.
All slides were assessed by two oral pathologists, who were unaware of the type of technique by which the material was collected. For comparative analysis of both techniques, four parameters were used such as (a) nuclear and cellular diameter, (b) cellular distribution, (c) cellular clarity, and (d) sample adequacy.
The results were then analyzed with IBM SPSS 20 (Chicago, IL, U.S.A.) software using the descriptive statistics such as mean and standard deviation and inferential statistics such as t-test and one-way ANOVA. The level of significance was set at 5%.
| > Results|| |
Parameters such as sample adequacy and cellular clarity showed a statistically high significance between the oral rinse-based cytology and conventional exfoliative cytology. When a comparison of nuclear diameter was done between the two techniques, no significant difference was seen (P < 0.001) [Table 1], [Figure 1] and [Figure 2]. When the sample adequacy was studied, the oral rinse-based cytology showed statistically high significant results (P < 0.001) in comparison to the conventional cytology [Table 2] and [Graph 1]. Similarly, when the cellular distribution [Table 3], [Graph 2], [Figure 3] and [Figure 4] and cellular clarity [Table 4], [Graph 3], [Figure 3] and [Figure 4] were studied, the oral rinse-based cytology showed statistically high significant difference (P < 0.001) as compared to conventional exfoliative cytology.
|Figure 1: Photomicrograph of nuclear and cellular dimensions of the cells using exfoliative cytology in squamous cell carcinoma (Pap, ×40)|
Click here to view
|Figure 2: Photomicrograph of nuclear and cellular dimensions of the cells using oral rinse-based cytology in squamous cell carcinoma (Pap, ×40)|
Click here to view
|Table 2: Comparison between groups for sample adequacy in conventional exfoliative cytology and oral rinse-based cytology|
Click here to view
|Table 3: Comparison between groups for cellular distribution in conventional exfoliative cytology and oral rinse-based cytology|
Click here to view
|Figure 3: Photomicrograph of cells in control group using exfoliative cytology (Pap, ×40)|
Click here to view
|Figure 4: Photomicrograph of cells in control group using oral rinse-based cytology (Pap, ×40)|
Click here to view
|Table 4: Comparison between groups for cellular clarity in conventional exfoliative cytology and oral rinse-based cytology|
Click here to view
| > Discussion|| |
Early detection of dysplastic changes helps in circumscription of the menace of oral cancer. There are several techniques employed for early detection of oral cancer, which include (1) scalpel biopsy, (2) punch biopsy, (3) fine needle aspiration cytology, (4) exfoliative cytology, (5) chemiluminescent techniques, (6) brush biopsy, (7) saliva-based tests, and (8) blood-based tests. Among the above-stated techniques, scalpel biopsy is considered as the gold standard. Exfoliative cytology is the microscopic examination of shed or desquamated cells from the epithelial surface usually the mucous membrane. The rationale of exfoliative cytology lies in the epithelial physiology. As a part of physiological turnover, there is continuous exfoliation of cells. In the case of malignancy, the deeper cells that strongly adhered to normal conditions become loose and exfoliate along with superficial cells. The most common drawback of exfoliative cytology is false positivity and false negativity but is impending. The ideal requisites for a useful diagnostic technique include the following: Simple, nonaggressive, less time consuming, reproducible, painless technique, well tolerated by patients, and sufficient collection of cells. The oral rinse-based cytology fulfills the above criteria. The added advantages of this method are that they do not require any specific armamentarium or trained personnel. A cytobrush was introduced in 1980 for cervical smears in gynecological lesions, which evolved major interest in oral cytology. A study conducted to compare the efficiency of cytobrush with that of wooden tongue spatula showed that the cytobrush was more efficient than the wooden spatula in terms of cell dispersion and cell yield. The oral brush biopsy with computer-assisted analysis is a computer-assisted method for the analysis of cellular samples collected using a patented brush which is noninvasive and simple. The scanned digital microscopic image of the cells collected is analyzed by the computer using a specialized neural network-based image processing system, designed to detect oral precancerous and cancerous lesions in the oral cavity. However, some authors were of the opinion that cancer is a poor man's disease and the method of diagnosis of oral cancer should be economical and cheap. Hence, these authors suggested that the use of oral brush biopsy was irrelevant for use in the developing countries. In addition, all these methods are expensive and require an extensive laboratory set up with trained personnel to conduct the procedure. Horowitz et al. in their study reported that only 10% of dentists had done an oral cytology smear, of which only 42% were taught to make a smear and 96.9% of dental offices lacked the necessary materials required to perform exfoliative cytology. This study focuses on the study of lesional cells shed in oral rinse-based cytology, making it simpler and easy to perform in a laboratory with basic setup facilities than the conventional exfoliative cytology. The oral rinse-based cytology offers repeatable preparations than conventional exfoliative cytology and also reduces the problems related to sampling, fixation, and cell morphology. It also reduces the false negative results. Various studies based on oral liquid-based cytology were conducted. All these studies on liquid-based cytology utilized a brush to collect the lesional cells and, in comparison to this, the present study uses the oral rinse-based method to collect the cells. Hence, this study too can be considered as a liquid-based cytologic method. Hayama et al. conducted a study to compare the specimen adequacy and diagnostic agreement between liquid-based preparations using a brush and conventional cytology in oral premalignant and malignant lesions. From this study, they concluded that both the smears were diagnostically reliable and the liquid-based method showed an overall improvement on sample preservation, specimen adequacy, cell morphology, and reproducibility. In microbiology, the oral rinse-based technique has been used for long, especially for the study of candida colonization. This similar technique was also used to study oral squamous cell carcinoma. In the present study, we found that both techniques are diagnostically reliable, showing good specimen adequacy and cellular morphology. Also, we detected some presence of microbial colonies; hence, the oral rinse can also be used in microbiology. In a study conducted by Callimeri and Smith, it was concluded that nuclear cytoplasmic ratio is one of the most consistent findings to detect the progress of malignancy. In the present study, no significant difference was seen in the increase in nuclear cytoplasmic ratio in both oral rinse-based cytology and conventional exfoliative cytology. Because of the added advantages of oral rinse-based cytology, such as cost effectiveness and patient compliance, this technique can be utilized for mass screening and regular follow-up wherever biopsy is contraindicated.
| > Conclusion|| |
This study concludes that the oral rinse-based cytology shows an improved quality in cell morphology, cellular clarity, and sample adequacy and, hence, aids in the detection of dysplastic features. The oral rinse-based preparation can thus be considered as a convenient alternative to conventional exfoliative cytology whenever a surgical biopsy is not feasible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Thomson PJ. Field change and oral cancer: New evidence for widespread carcinogenesis? Int J Oral Maxillofac Surg 2002;31:262-6.
Babu M, Sayed MN. The relevance of CDX brush biopsy in diagnosing early oral cancer in developing countries. Oral Maxillofac Pathol J 2011;2:115-6.
Mehrotra R, Gupta DK. Exciting new advances in oral cancer diagnosis: Avenues to early detection. Head Neck Oncol 2011;3:33.
Seifi S, Feizi F, Mehdizadeh M, Khafri S, Ahmadi B. Evaluation of cytological alterations of oral mucosa in smokers and waterpipe users. Cell J 2014;15:302-9.
Hayama FH, Motta AC, Silva Ade P, Migliari DA. Liquid-based preparations versus conventional cytology: Specimen adequacy and diagnostic agreement in oral lesions. Med Oral Patol Oral Cir Bucal 2005;10:115-22.
Kujan O, Khattab A, Oliver RJ, Roberts SA, Thakker N, Sloan P. Why oral histopathology suffers inter-observer variability on grading oral epithelial dysplasia: An attempt to understand the sources of variation. Oral Oncol 2007;43:224-31.
Mulki S, Shetty P, Pai P. Oral rinse as a simpler approach to exfoliative cytology: A comparative study. J Clin Diagn Res 2013;7:3036-8.
Sivapathasundharam B, Kalasagar M. Yet another article on exfoliative cytology. J Oral Maxillofac Pathol 2004;8:54-7. [Full text]
Mulki S, Shetty P, Pai P. Oral rinse-based cytology and conventional exfoliative cytology: A comparative study. J Cancer Res Ther 2015;11:129-35.
Cowpe JG. Quantitative exfoliative cytology of normal and abnormal oral mucosal squames: Preliminary communication. J R Soc Med 1984;77:928-31.
Moralis A, Kunkel M, Reichert TE, Kosmehl H, Driemel O. Identification of a recurrent oral squamous cell carcinoma by brush cytology. Mund Kiefer Gesichtschir 2007;11:355-8.
Sandler HC. Veterans administration cooperative study of oral exfoliative cytology. Acta Cytol 1963;7:180-2.
Ogden GR, Cowpe JG, Green M. Cytobrush and wooden spatula for oral exfoliative cytology. A comparison. Acta Cytol 1992;36:706-10.
Mehrotra R, Hullmann M, Smeets R, Reichert TE, Driemel O. Oral cytology revisited. J Oral Pathol Med 2009;38:161-6.
Horowitz AM, Drury TF, Goodman HS, Yellowitz JA. Oral pharyngeal cancer prevention and early detection. Dentists' opinions and practices. J Am Dent Assoc 2000;131:453-62.
Coulter WA, Murray SD, Kinirons MJ. The use of a concentrated oral rinse culture technique to sample oral Candida
and lactobacilli in children, and the relationship between Candida
and lactobacilli levels and dental caries experience: A pilot study. Int J Paediatr Dent 1993;3:17-21.
Nagata S, Hamada T, Yamada N, Yokoyama S, Kitamoto S, Kanmura Y, et al.
Aberrant DNA methylation of tumor-related genes in oral rinse: A noninvasive method for detection of oral squamous cell carcinoma. Cancer 2012;118:4298-308.
Hegde V. Cytomorphometric analysis of squames from oral premalignant and malignant lesions. J Clin Exp Dent 2011;3:441-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]