|Year : 2015 | Volume
| Issue : 3 | Page : 370-374
Use of colposcopy for diagnosing oral mucosal lesions: An illusion or a realistic possibility?
R Issrani1, R Ammanagi2, V Keluskar3
1 Department of Oral Medicine and Radiology, Saraswati Medical and Dental College, Lucknow, Uttar Pradesh, India
2 Department of Oral Medicine and Radiology, Maratha Mandal's NGH Institute of Dental Sciences and Research Centre, Belgaum, Karnataka, India
3 Department of Oral Medicine and Radiology, KLE V.K Institute of Dental Sciences, Nehru Nagar, Belgaum, Karnataka, India
|Date of Web Publication||18-Feb-2016|
Department of Oral Medicine and Radiology, Saraswati Medical and Dental College, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
As oral physicians, we come across many oral mucosal lesions that usually require a supplementary biopsy with histopathologic examination to establish a definite diagnosis. The selection of the site for biopsy is the most important criteria to arrive at a correct diagnosis. As biopsy site is a subjective choice, it is possible that the biopsy specimens are taken from unrepresentative areas of the lesion. At present, though there are simple chair side methods to aid the diagnosis of such changes, there is a high risk of false positives. Hence, there is a need of a simple and reliable method for selecting the most appropriate area for biopsy. One such method is colposcopy that may be beneficial as compared to routine clinical examination. Hence, this article stresses on the colposcopic method that can be used to select biopsy sites which should be evaluated in further clinical studies.
Keywords: Biopsy, colposcopy, direct oral microscopy, epithelial lesions, oral malignancy, potentially malignant
|How to cite this article:|
Issrani R, Ammanagi R, Keluskar V. Use of colposcopy for diagnosing oral mucosal lesions: An illusion or a realistic possibility?. Indian J Cancer 2015;52:370-4
|How to cite this URL:|
Issrani R, Ammanagi R, Keluskar V. Use of colposcopy for diagnosing oral mucosal lesions: An illusion or a realistic possibility?. Indian J Cancer [serial online] 2015 [cited 2019 Aug 20];52:370-4. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/370/176724
| » Introduction|| |
Surprisingly change is the only thing that is constant, so to keep pace with the shifting trends and the world ahead, oral physicians need to endeavor the advances taking place in dentistry. One such advancement is colposcopy that offers advantages in selecting more representative sites for biopsy than routine clinical examination alone which is also simple and painless chair side diagnostic method.
The incidence of potentially malignant epithelial lesions (PMELs) is steadily increasing globally. Clinical diagnosis of oral cancer is not difficult when the lesion is obviously invasive or when the patient experiences pain, functional limitation, or regional lymphadenopathy. Conventional visual examination using normal (incandescent) light, has traditionally been the mainstay of oral malignancy screenings for decades, anyhow its utility remains controversial. Conversely, the diagnosis of PMELs of the oral mucosa cannot be based solely on clinical findings. An early detection and prompt treatment enables an improvement in the prognosis of malignancy. In spite of advancement in the early detection, there is increased mortality and morbidity related to oral malignancies. Therefore, biopsy with a histopathologic examination of the lesion is necessary to establish a definitive diagnosis.
Though, biopsy with histopathologic examination is still considered as gold standard in the diagnosis of PMELs and oral malignancy, but the selection of the site for biopsy is still critical. The selection of biopsy site is a subjective choice, and it is possible that the biopsy specimens are taken from unrepresentative areas of the lesion or before the morphologic changes could be detected in PMELs. At present, though there are simple chair side methods including staining with toluidine blue, light based detection systems, and exfoliative cytology or brush biopsy to aid the diagnosis of such changes, there are related disadvantages with these methods.
Toluidine blue may be used to identify a suitable site for biopsy, but studies have shown that the risk of false-positive staining may be as high as 30%. Questions have also been raised regarding the risks of developing malignancies associated with the use of toluidine blue because it shows an affinity for DNA. A study conducted in India (2008) concluded that the use of ViziLite or VELscope along with a conventional screening examination for lesions deemed clinically innocuous was not beneficial in identifying dysplasia or malignancy.
The use of oral exfoliative cytology in clinical practice had been declined due to the subjective nature of its interpretation and only a small number of abnormal cells identifiable in a smear.
Therefore, a technique for non-invasively detected choosing the appropriate site for biopsy can save patients from multiple biopsies and allow a broader range of diagnoses which can aid in early detection of oral potentially malignant lesions. With the aim of improving the efficiency of these diagnoses, techniques are being developed to complement clinical examination and to facilitate the identification of PMELs.
One such technique is colposcopy, also known as direct oral microscopy that offers advantages in selecting more representative sites for biopsy than routine clinical examination and other available chair side diagnostic methods.
Colposcopic examination is an established technique for diagnosis in gynecology which is used to observe the mucosa of cervix for premalignant and malignant changes. Various authors have tried to adapt gynecologic methods of examination to the oral cavity as there is similarity between both the mucosae. The word “colposcope” is derived from the Greek words kolpo meaning fold or hollow and skope meaning examine. In 1925, Hinselmann reported the construction of the first colposcope. Colposcopic evaluation of the cervix and vagina is based on the finding that premalignant and malignant epithelium have specific macroscopic characteristics related to the vascular pattern, intercapillary distance, surface contour, color tone, and clarity of demarcation.
Colposcope functions as a lighted binocular microscope and connected to a video monitor that magnifies the area of interest 6-40 times its normal size, using an external white light for illumination. Low power (2× to 6×) may be used to obtain a general impression of the surface architecture. Medium (8× to 15×) and high (15× to 25×) powers are utilized to evaluate the vagina and cervix. The higher powers are often necessary to identify certain vascular patterns that may indicate the presence of more advanced precancerous and cancerous lesions. Various light filters are available to highlight different aspects of the surface of the cervix.
Acetic acid solution and iodine solution (Lugol's or Schiller's) are applied to the surface to improve visualization of abnormal areas. Acetic acid dissolves mucous and accentuates atypical areas by inducing intracellular dehydration and coagulation of protein, , that is believed to be due to a reversible osmolar change resulting in cytoplasmic dehydration and cytoplasmic membrane collapse. The degree to which the epithelium takes up the acetic acid stain is correlated with the color tone or intensity, the surface shine, and the duration of the effect, and, in turn, with the degree of neoplastic change in the lesion. Higher grade lesions and invasive malignancies are more likely to turn dense white rapidly.
Macroscopic characteristics seen under colposcope
The colposcopic image is the result of the reciprocal relationship between the epithelium and the stroma. The intensity of color represents the ratio of reflected and absorbed light and is related to:,,
- The number of layers of epithelium
- The optical density of the epithelium
- The vascularity and the nature of the underlying stroma
- Tissue chromophores
- The amount of hemoglobin.
A study conducted in United Kingdom (1997) on the association between tumor progression and vascularity in the oral mucosa highlighted that tumorogenesis is associated with the formation of new blood vessels. This tumorogenesis activity may be inferred in the histologic sections by measuring the density of vasculature. It was concluded that there is a close association between vascularity and tumor progression in the oral mucosa.
The vascular changes described in colposcopic literature seen in the normal uterine cervix mucosa are:
In areas of dysplasia and carcinoma in situ of the uterine cervix, specific vascular pattern seen are:
- Punctation- It is characterized by dilated, often twisted, irregular, hairpin-type vessels. It is also called ground appearance and is common [Figure 1c]
- Mosaic- Another pattern of the vessels in dysplasia is called mosaic. Like punctation vessels, true mosaic vessels are usually seen in sharply demarcated areas [Figure 1d]
- Atypical vessels- When it is difficult to describe the pattern of the vessels, the term atypical vessels is used [Figure 1e].
Capillary punctation, mosaic, or atypical patterns are encountered in malignant lesions. Therefore, if one of them is present, this is an indication for biopsy and histopathologic examination.
Intercapillary distance more than 50-200 µm indicates malignancy.
A smooth, regular surface contour is normal in mature, squamous epithelium and squamous metaplasia. When cervical intraepithelial neoplasia (CIN) occurs, as it progresses in severity, the surface may become rougher and more irregular. In areas of invasive carcinoma, the surface contour may be grossly uneven, having a cauliflower-like appearance.
Clarity of demarcation
Areas with significant CIN demonstrate a sharp border with the surrounding pale pink normal tissue. A sharply contrasting border around a geographic area of white epithelium signifies an area of epithelial abnormality. Areas of squamous metaplasia or human papilloma virus (HPV) demonstrate a diffuse, poorly defined border with normal tissue.
Therefore, colposcopic features suggestive of invasive carcinoma could be:
- Irregular surface contour, erosion, or ulcer
- Dense acetowhite change
- Wide irregular and coarse punctation and mosaic
- Atypical vessels.
Applications of colposcopy in gynecology
- As an integral part of every gynecologic examination in concert with cytology
- To display and localize lesions suspected cytologically
- To clarify the nature of clinically suspicious lesions
- As a part of a sexual assault in forensic examination
- To diagnose lesions caused due to HPV infections 
- To diagnose lesions that occurs due to immunosuppression such as HIV infection, or an organ transplant.,
Suggested applications of colposcopy in oral cavity with review of literature
Colposcopy allows non-invasive examination of the oral tissues in situ at high magnification and at the same time has good resolution. Surface topography and the degree of keratinization of the epithelium may be readily observed and documented. Three-dimensional observation of such surface structures as the papillae of the tongue is possible because of the depth of field combined with good resolution. Direct observation of living structures could offer an alternative to replica models. As the instrument allows simultaneous viewing of surface cells of submucosal vessels, it is hoped that techniques will be developed for documentation without the need for vital staining. Erythrocytes have a diameter of 7 µm and the resolution of the colposcopic instrument is 2 µm, allowing ready and detailed observation of flow in the larger blood vessels. It is considered that this feature could be of advantageous in the monitoring of grafting procedures in the oral cavity. Examination of the occlusal surfaces of the teeth by colposcopic method reveals such details as wear facets and the margins of restorations.
An important area of application may be in the diagnostic evaluation and monitoring of treatment of oral malignancy. The comparative effects of different treatment modalities, such as radiation and chemotherapy on the junction between the normal tissue and tumor could also be studied. Areas of surface dysplasia could be mapped to indicate the full extent of epithelial change before biopsy and surgery. Most patients with premalignant and malignant conditions show changes in the vascular picture which can be easily appreciated well by direct oral microscopy. Many patients with oral malignancy have a marked inflammatory infiltrate. This inflammation interferes with the evaluation of dysplastic changes. In comparison, a biopsy specimen selected by colposcopy rarely shows a severe inflammatory infiltrate, hence is of more advantage in diagnosing dysplasia.
Various authors have tried to adapt gynecologic methods of examination to the oral cavity, but with limited success. A pilot study was conducted in Sweden (2000) on direct intraoral microscopy and its value in diagnosing mucosal lesions. Direct oral microscopy was performed in 35 patients with various clinical diagnoses, such as leucoplakia, oral lichenoid lesions, or suspected malignancy. First, the oral mucosa was examined with direct microscopy, and the most representative site, according to colposcopic criteria, was selected. Then, the mucosa was clinically inspected by an independent examiner. The best site for biopsy according to clinical criteria was noted, and any difference in biopsy sites was recorded. Biopsy specimens were taken from two of these sites. Twenty-nine patients showed changes in the vascular picture on microscopy, according to the colposcopy criteria. In fourteen patients the biopsy sites identified by direct oral microscopy showed more advanced histologic signs than those selected by routine clinical examination. It was concluded that direct oral microscopy of mucosal lesions seems to offer advantages in selecting more representative sites for biopsy than routine clinical examination alone.
A study conducted in India (2011) on fifty oral mucosal lesions had concluded that colposcopy would aid in early and better diagnosis and treatment planning of oral premalignant and malignant lesions by assessing the various vascular patterns in the mucosa.
A recently developed optical instrument which is a modification of colposcope is the contact microcolpohysteroscope which allows one to observe the cervix and endocervix at magnifications of 1:1-1:150. More important, it permits examination of the squamocolumnar junction when it is obscured within the endocervix. A study conducted in Sweden (1989) compared standard colposcopy with a microcolpohysteroscopy technique in 65 patients with abnormal papnicolaou smears, and concluded that using contact microcolpohysteroscopy, the clinician can map out geographically entire cervical intraepithelial neoplastic lesions; locate correctly the epicenter of most lesions; and in cases of inadequate colposcopy, visualize the squamocolumnar junction within the cervix. The results of this study suggested that microcolpohysteroscopy is a diagnostic tool that can precisely qualify and localize a cervical lesion.
A study conducted regarding the application of contact microcolpohysteroscopy for examination and recording of surface topography of hard and soft tissues of the oral cavity concluded that this is a promising non-invasive method of observation of tissue surface at higher magnification. The authors considered that microcolpohysteroscope techniques, with minor modifications for oral conditions, offer a simple, non-invasive approach to detailed observation of the surface topography of the oral tissues. Modifications of contact microcolpohysteroscope for oral use are described, and potential applications for diagnosis and research in dentistry are proposed.
Future scope of colposcope
It is considered that colposcopy may bridge a gap between microscopic examination of the surface morphology of the oral tissues and histological examination for teaching purposes. The instrument could be combined with video techniques with appropriate video recording equipment; quality photographic records may be obtained from individual frames. It is not possible to determine the progression from dysplasia to carcinoma on the basis of the clinical findings. Similarly, such a progression of mucosal changes cannot be detected because these areas may contain foci of varying degrees of dysplasia, reversible or irreversible. Regular follow-up examinations are therefore essential for precancerous lesions, such as non-homogeneous leukoplakias. Hopefully, direct oral microscopy will be used in future to follow mucosal lesions and detect signs of progression as, at present this seems to be the only way to non-invasively evaluate vascular changes in the oral mucosa.
Merits of colposcopy
Following may be the main advantages of using colposcopy:
- High resolution
- Good magnification and illumination
- Easy to use
- Accuracy ~70%-98%.,,
Demerits of colposcopy
The chief disadvantages are the complexity and cost.
| » Conclusion|| |
As oral physicians we know “screening is the key to early detection,” especially in cases of PMELs and oral malignancies and colposcopy with its enhanced appearance ability makes it possible to see what a naked eye cannot see, allowing early screening and detection of oral mucosal lesions as every tiny bit of tissue is precious and with these recent measures like colposcopy we can attempt to preserve them even better.
However, further research with clear objectives, well defined population cohort, and sound methodology is strongly required, and also studies on use of various staining methods compared with colposcopic examination are recommended for selecting representative sites for biopsy so as to verify whether colposcopy compared to various staining methods is ”an illusion or a realistic possibility?”
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[Figure 1a], [Figure 1b], [Figure 1c], [Figure 1d], [Figure 1e]