I N V E S T I G AT I O N S O F

ORAL CANCER
Batch 11

DR.PREETHY MARY DONALD

ASSOC.PROF
ORAL MEDICINE AND ORAL RADIOLOGY
 LEARNING OBJECTIVES
1. Differentiate the etiological factors, clinical features,
investigations and management principles for oral cancer
(C4)

2. Apply the TNM staging of oral cancer (C3)

3. Summarize the oral complications of cancer therapy

(chemotherapy and radiotherapy) and their management
(C6)
 Investigations

Aids in confirming the diagnosis

Vital Staining Plain radiographs

Exfoliative CT
cytology
MRI
Brush biopsy
Ultrasonagraphy
Tissue biopsy PET SCAN
Newer Diagnostic tools techniques

Velscope

Vizilite plus

Raman spectrosopy
VITAL STAINING

• Procedure where living cells take up certain dyes, which then selectively stains
some elements in the cells like mitochondria, lysosomes,lipid veicles etc
Vital stains:
- Toluidine blue
- Lugol’s iodine
- Methylene blue
- Rose Bengal dye
- Acetic acid
 Toluidine blue staining

• Tolonium chloride
• Used to detect oral premalignant and malignant lesions
• Acidophilic metachromatic dye – ability to bind to acidic tissue
components – binds to nuclear material which contains high DNA
and RNA content – dysplastic and neoplastic cells contain more
nucleic acid quantitatively than normal cells.
Toluidine blue rinse staining
procedure
1. Rinse mouth with water for 20 sec
2. Rinse with 1% acetic acid for 20 sec
3. Rinse mouth with 5ml of 1% toluidine blue
solution
4. Rinse with 1% acetic acid for 20sec
5. Rinse with water

Biopsy site selected on the basis of clinical

appearance of lesion and staining results

Royal blue – positive

Light blue – doubtful
No color - negative

Histopathological examination
Principle of Lugol’s iodine
staining procedure:
- Based on glycogen content of
cytoplasm.
- Reaction is known as iodine - starch
reaction.
- In normal cells, brown color noticed
due to high glycogen content of
normal epithelial cells.
- In cancer cells, there is enhanced
glycolysis, so does not promote
iodine starch reaction, hence no
color change in dysplastic
epithelium.

Lugol’s Iodine staining procedure

Apply 5% Lugol’s solution
EXFOLIATIVE CYTOLOGY
BRUSH BIOPSY Advantages:
Cellular
representation
Substitute to
from each of the Uses a
conventional
Permits three layerrs cyto brush
exfoliative
cytology complete ‘Oral CD X’
transepithelial
biopsy specimen
collection

Interpretation:
Interpretation:
o Atypical :
o Inadequate:
abnormal epithelial
insufficient
changes
specimen
o Positive:
o Negative:
definitive cellular
no epithelial
evidence of epithelial
abnormality
dysplasia or carcinoma
BIOPSY
Indications
• If any clinical suspicion of
malignancy
• Enlarging mass
• Chronic ulceration
• Induration on palpation
• Persistence of mucosal changes
even after removal of mucosal
irritants
BIOPSY
Contraindications
• Biopsy of a vascular lesion;
caution should be exercised for
any lesion with red , blue or Medical clearance should be
purple color obtained prior to biopsy in
case of medically
• Lesions which blanch or pulsate compromised patient
on palpation
• Lesions near anatomic structures
✓floor of mouth – submandibular
duct
✓Parotid region – facial nerve
 Ulcerated erthroleukoplakia

Incisional biopsy Excisional biopsy Punch biopsy

• Provides representative sample of tissue • For complete removal of a lesion, for • Used for incisional biopsy or excision
functional and aesthetic purposes of a small lesion at an accessible site
• To confirm clinical diagnosis • Lateral tongue and buccal mucosa
• Small pedunculated exophytic lesions
 VIZILITE
Principle: Chemiluminiscence
The blue white light produced is absorbed by the cells of the
normal mucosa (with normal nuclear-cytoplasmic ratio i.e. 1:4);
whereas reflected by the cells with abnormal nuclei including
dysplastic and neoplastic cell.

The ratio between the nucleus and the cytoplasm increases

until the nucleus takes up nearly 100% of the cell volume. Thus,
reflection of light occurs in cancerous cells.
Application of acetic acid solution removes debris , disrupts the
glycoprotein barrier on surface epithelium and dessicates the
mucosa, allowing better penetration of light; hence oral
mucosal abnormalities are better visualized
VELSCOPE
Principle: Narrow emission tissue fluorescence
Tissue fluorescence is caused by fluorophores, which are chemical
compounds that react to light excitation. When exposed to the blue
light of the VELscope, fluorophores respond by emitting their own light
at a longer wavelength, which can be observed via the optical filter in
the VELscope eyepiece.

Normal fluorescence patterns typically appear as a bright apple-green

color, indicating that the fluorophores in the tissues of the oral mucosa
are responding normally.
Abnormal fluorescence patterns typically arise from:
An increase in metabolic activity in the epithelium and they appear
dark.
IMAGING
MODALITIES
PLAIN RADIOGRAPHIC EXAMINATIONS

finer bone invasion trabecular

Intra-oral Periapical radiograph
details structure

Occlusal radiograph
destruction of destruction of bone
lamina dura in anterior region
OPG

Ill-defined
thinning of cortical
destruction of bone
plates leading to
with ragged
pathologicalfracture
borders

destruction of floor
of nasal cavity, destruction of bone
maxillary sinus and around teeth
mandibular canal
PLAIN RADIOGRAPHIC EXAMINATIONS

Moth eaten appearance

PLAIN RADIOGRAPHIC EXAMINATIONS

To detect distant
metastasis
 Helps in
CT SCAN ✓ assessing the size of tumour
✓ assessing extent of bony involvement by the tumour mass

Helps in
MRI ✓ evaluating possibility of organ invasion
e.g intracranial invasion
✓ Lymph nodes not accessible during clinical examination
CT scan with
intravenous
contrast
Extensive metastasis
which involves caroid artery, cranium,
MRI scan with parapharyngeal space
Gadolinium
contrast
POSITRON
EMISSION ✓ helps in localising a lesion
TOMOGRAPHY ✓ PET scan easily picks up
SCAN increased activity (metabolic) of
tumour cells ass they are rapidly
dividing.
ULTRASOUND
✓ Assessment of cervical lymph nodes
Location, number, shape, dimensions,
margins and internal structure

✓ Abdominal ultrasound to check

distant metastasis
COCHRANE DATABASE OF SYSTEMATIC REVIEWS
The link below give a list of routine and advanced investigations, principle, procedure and
results. ( or type the words below in search box for further reading)

• https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010276.pub2/epdf/
full
COCHRANE DATABASE OF SYSTEMATIC REVIEWS
The link below give a list of routine and advanced investigations, principle, procedure and
results.

• https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010276.pub2/epdf/
full
TNM STAGING

Tumor-Node-Metastasis
• Anatomic staging system that describes
➢anatomic extent of primary tumor in cm - T
➢Involvement of regional lymph nodes - N
➢Distant metastasis - M
TNM STAGING
TNM STAGING