Evaluation of various Oral Cancer Diagnostic Technique

Dr.G. Ulaganathan., M.D.S, Dr.K.Thanvir Mohamed Niazi M.D.S,

Dr.Soundarya Srinivasan M.D.S, Dr.V.R.Balaji, M.D.S,

Dr.D.Manikandan, M.D.S, K.A. Shahul Hameed ME, A. Banumathi.ME.Ph.D.

Abstract

Oral cancers are one of the most commonly occurring malignant tumors in the head and
neck regions with high incident rate and mortality rate in the developed countries than in
the developing countries. Generally the survival rate of cancer patients may increase
when diagnosed at early stage, followed by prompt treatment and therapy. Recently,
cancer diagnosis and therapy design for a specific cancer patient has been performed with
the advanced computer aided techniques. The responses of the cancer therapy could be
continuously monitored to ensure the effectiveness of the treatment process that hardly
requires diagnostic result as quick as possible to improve the quality and patient care.
This paper gives an overview of oral cancer occurrence, different types, and various
diagnostic techniques. In addition, a brief introduction is given to various stages of
immuno-analysis including tissue image preparation, whole slide imaging and
microscopic image analysis.

Keywords: Histopathology, Biomarker, Immunohistochemistry, Microscopic image

analysis, Whole-slide imaging

1. Introduction

Oral cancer is a frequently occurring and is the sixth most common cancer worldwide.
Oral cancer is considered to be one of the most challenging malignancies of the head and
neck regions that reportedly affect more than half million people every year worldwide
[1] [2]. Especially, oral squamous cell carcinoma (OSCC) accounts for eighty-five
percentages of all oral cancer which affects its site or origin and can spread to cervical
node, lungs, liver and bones. During the year 2012, three million oral cancer patients
(both sexes) have been identified out of which 145,000 cases were fatal. The incident
rates of oral cancer are higher in the developed countries than in the developing
countries. In India, the incident rate of oral cancer is 12.6 % per one million populations
and remains the most common cancer in other Asian countries. In addition, the incident
rate remains higher in some of the developed countries namely Australia, New Zealand,
Germany, Poland, Denmark, Scotland and the USA. The five-year survival rate of early
stage oral cancer patients is approximately 82%, and the advanced stage is about 20%.
However, the five-year survival rate increased in developed countries such as the USA
during the period from 1983 to 2006. At the same time, a negative trend is noticed in
some countries like Brazil, Egypt, Japan, UK and Netherland where the number of
causality has increased due to oral cancer [1].
Figure 1. Different types of potentially malignant oral lesions (a) carcinoma of tongue,
(b) erythroplasia, (c) leukoplakia, (d) proliferative verrucous leukoplakia, (e) sublingual
keratosis, and (f) candidal leukoplakia

The main risk factors associated with the development of oral cancer and potentially
malignant lesions (PML) are smoking, consuming alcohol and betel quid [3]. Early
diagnosis of OSCC followed by prompt treatment can offer the best chance for cure and
improve the survival rate of patients. Unlike others, the malignant portion of the oral
cavity can be easily analyzed visually and/or different types of noninvasive method can
also be used as a tool to in- crease the accuracy of physical examination. In spite of all,
detection of OSCC is still an important and challenging problem for clinicians due to the
fact that many lesions are asymptomatic at an early stage, and so regular screening of
patients is mandatory. Generally clinically visible PMLs over oral cavity regions may
become OSCC at later stage. Figure 1 shows few potentially malignant oral lesions
namely, (a) carcinoma of tongue, (b) erythroplasia, (c) leukoplakia, (d) proliferative
verrucous leukoplakia, (e) sublingual keratosis, and (f) candidal leukoplakia [4].

 Squamous cell carcinoma of tongue (SCC) (Figure 1 (a)): This is more

aggressive malignant tumor than conventional SCC appears in other regions of
our body. The main cause for this tumor is unknown, however, the factors such as
smoking, radiation, exposure to arsenic and coal tar may influence a lot for its
development.
 Erythroplasia looks as bright red velvety plaques as displayed in Figure 1 (b),
which is rarely occurred and clinically difficult to characterize. The main causes
are presumed to be similar to the causes of SCC, and also mostly found in elderly
people.
 Leukoplakia appears like thick, white patches on gum, inside of the cheeks,
bottom of the mouth and sometimes on tongue also. These patches cannot be
easily scraped off. Generally, most leukoplakia symptoms are benign, a few cases
may become malignant, hence, it is not too dangerous, but sometimes may
become so serious. Therefore, a patient with any one of these symptoms must
 consult a dentist for further treatment. Figure 1 (c) to (f) show some types of
leukoplakia.

Early diagnosis of oral cancer and treatment aims at increasing the survival rate of a
patient [5]. The standard method of revealing the oral lesion is benign or PML or OSCC
by conventional oral examination, followed by histopathological analysis of biopsy taken
from suspicious oral regions. In this process, pathologist use histopathological slides of
biopsy samples taken from a patient, examine them under a microscope and make
judgments based on clinico-pathological acumen [6]. The assessments are made only by
visual examination of the deviation in the cell structure, shapes, tissue distribution, and
grade of cancer. Hence, the results are purely qualitative and greatly suffered due to
uncertain specificity and sensitivity [7][8]. Moreover, the awareness of endangerment of
oral cancer among patients and also common people increases the demand for highly
sophisticated and precise diagnostic techniques, which can detect the malignancy at an
early stage. In order to meet these challenges, computer-aided diagnosis techniques has
been introduced that utilizes the advanced image processing and machine learning
techniques to produce quantitative diagnostic outcomes.

2. Different types of diagnostic techniques

The requirements of oral cancer diagnostic techniques have been increased in the recent
past in order to screen out malignant portion of oral lesion. Several diagnostic tools are
currently available in the market. Among the most commonly used techniques are:
histopathological study, vital staining, brush biopsy, and optical techniques.

 Histopathological examination is considered as golden standard test for cancer

diagnosis. The effectiveness of the outcome depending on several factors
including localization of suspected region and number of biopsy specimen taken
from the malignant and normal tissue region [9].
 Vital staining techniques are used to clinically highlight the malignant areas of
oral lesion. It may help to acquire biopsy samples but unfortunately these
techniques are not reliable.
 The brush biopsy techniques uses a tiny nylon brush to collect cytology samples
which are scanned and analyzed by computer software in order to recognize
whether individual cells are cancerous or not. Pathologists further examine the
abnormal cells and positive results are attained only by a conventional incisional
biopsy and histology examination.
 Incisional and excisional biopsies removing the part of the lesion with the
inclusion of normal tissue is incisional biopsy. An attempt to clear the entire
lesion is excisional biopsy. The possibility is that if the lesion is curable by local
removal an excisional biopsy is recommended
The Biopsy was taken in the Department of OMFS, C.S.I College Of Dental Science and
Research, Madurai

Generally, the abnormalities of cellular and molecular level in the tissues are not visible
to human eye. It can only be observed by passing light through the tissues and detecting
the changes in the optical spectrum. Optical spectroscopy techniques are commonly
employed to locate malignant site of oral lesion prior to biopsy and histology
investigation at early stages. 
The biomarker investigations became popular after the
introduction of cellular and molecular studies about abnormalities in protein expression
that have shown promising results in early diagnosis of oral cancer [10] [11]. The most
popular and predictive biomarkers related to oral cancer development thus far reportedly
available are TSG p53, TSG p16, Ki-67 antigen and DNA ploidy [4] [10]. For example
p53 protein is regarded as an early event in carcinogenesis of OSCC. The p53 protein has
been called as the guardian of genome, due to its ability in maintaining genomic stability,
cell cycle control and apoptosis. In normal tissues, p53 protein has a short half-life and
the amount of expression is very small which is normally undetectable. Conversely, the
mutant p53 protein has prolonged half-life. It can remain in the tissues longer and can
accumulate in cell nuclei to the levels that are detectable using specific staining process.
Hence, p53 protein expression deserves particular attention in the case of early detection
of oral cancer. Immunohistochemical (IHC) staining can detect the presence of the
mutant p53 gene and it encodes protein with prolonged half-life, which induces over-
expression of p53 protein in the nuclei. The p53 expression is considered to be positive,
when the cell nucleus is detected with strong brown color which is shown in Figure 2. At
present, these biomarker studies are adjuncts to help the routine histological examination,
and their effective usages are still not commissioned due to the initial investment cost,
lack of awareness, nature of complexity and limited number of studies reported up to
date.
Figure 2: P53immunostained tissue image of OSCC. (a) 5x magnification; (b) Exported
region(0.6mm); (c) Zoomed version of this slide under 40x in which positive (brown)
and negative (blue) staining of p53 protein cell nuclei are marked by P & N respectively.

3. Microscopic image analysis

Over the last decade, the nature of diagnostic methods and healthcare systems have been
changing rapidly due to the vast availability of cancer patient data for diagnosis [12] [13].
Generally, classical diagnosis procedures are restricted to few diagnostic outcomes which
mainly describe the stage/grade of the cancer or presence/absence of biomarkers such as
HER2, p53, ki-67, estrogen receptor, and progesterone receptor [14] [15] [16]. The
pathologists are well trained to extract the information from the tissue section that would
help the oncologist to design the best therapy for a patient [8]. And also, these data could
be used to understand the molecular characteristic of cancer with the view to improving
therapy for a specific cancer patient.
Microscopic imaging technologies have been
emerging in medical field to extract clinical and functional information from tissues and
molecules [17]. Onco- pathologists are highly dependent on high-resolution microscopic
images to assess the presence and the activity of target antigen in the tissues. In situ
evaluation of the specific protein activation provides critical information about the status
of tumor and it helps to design targeted therapy for a cancer patient. IHC is the most
powerful tool in this field that uses marked antibodies to relate specific proteins in situ
where the markers are located at sub-cellular regions namely nucleus, cytoplasm, and
membrane. The evaluation of stains at these locations provides information about the
nature and malignancy level of cancers.

IHC techniques are introduced during early seventies for the assessment of tissue slides
that have been given more importance in clinical research field after the introduction of
high throughput imaging devices, and gained more attention as it has the capability to
provide qualitative as well as quantitative diagnostic outcome [18]. The robustness of the
outcomes is highly dependent on quantitative measurement rather than qualitative
analysis of tissue slides, since manual outcomes are more subjective and suffers due to
observers variability. The reliability of manual evaluation of tissue images is naturally
subjective, heavily questioned and suffers due to inter/intra observer variability. In
particular, modern pathology demands personalized medicine and therapy design for a
specific cancer patient that requires the extraction of information about protein activity at
cellular level which cannot be easily obtained via visual examination [19]. Therefore,
IHC analysis through computer-aided techniques is highly recommended to measure
quantitative information from tissue under study.

4. Requirements of automatic techniques for IHC analysis

Generally pathologists have been working strenuously on evaluating benign nature of

tissue sections and their efforts can be used to analyze more complex or difficult
suspicious tissue sections of tumors. For example, 20% of tissue sections are reportedly
positive out of 1 million prostate biopsies performed every year in the USA, and the
similar scenarios are found in other countries [20]. With the recent advancement in
microscopic digital scanner, the whole tissue slides can be digitized and stored in
memory devices. And the availability of image analysis algorithms with the large set of
features, traditional way of diagnosis techniques could be replaced by digital pathologist
[21]. Therefore, the requirements of computer-aided diagnosis (CAD) systems for
medical image analysis have become increasing as it minimizes the workload on
pathologist in terms of the time consumption and processing cost.

For the past several decades, medical image analysis in cytology and radiology has been
active research field that resulted in numerous products pertaining to a specific disease
diagnosis [22] [23]. However, the imaging modalities, image features and automated
procedures of these systems are notably different from histopathology analysis that
cannot be directly applied to extract information from tissue section. Nevertheless,
histopathology related problems attracts re- searchers working in the field of medicine,
biochemistry and engineering due to tremendous development and production of
microscopic scanners and aided software and their support in biomedical field [24]. In
general histology images consist of more number of objects such as cell nuclei, stroma,
lymphocytes, etc. which are widely distributed over the entire tissue sections and each
needs to be accounted during diagnosis process.

Figure 3: Examples of different types of medical images (a) radiology, (b) cytology, &
(c) histopathology.

In the case of radiology, only a very few organs in the images are examined for
malignancy that usually located at a predictable place and mostly these images contain
gray pixels. At the same time, cytology images look similar to histopathology images in
terms of cell nuclei distribution; however, both images are taken at different magnitude
levels for analysis, i.e., cytology images generally acquired at higher magnification level
than histology images in order to capture in-depth information about internal cell nuclei
structures. Figure 3 shows a small portion of (a) radiology, (b) cytology [24] and (c)
histology images, in which histology images are more complex than other two due to the
factors such as overlapping cell nuclei, blurred cell nuclei boundaries by noise and poor
contrast. Nevertheless, these three automated systems have common sequence of steps
such as segmentation, feature extraction, and classification. Although, there are several
factors, which hinder the development of CAD systems for histopathology image
analysis, among the most common problems include: i) complexity and diversity of tissue
architectures are entirely different for each cancer tissue image, hence, it is very difficult
to develop a universal CAD system for tissue analysis; ii) the algorithms developed for
other medical image analysis cannot be easily adopted for histopathology; iii) no standard
ground truth is available for the evaluation of CAD systems; hence, the performance
outcomes are either fundamentally subjective or with minimal confidence testing. In spite
of all these circumstances, the unworkable quantitative measurement on tissue images
demands for the development of CAD systems and their important towards minimizing
the workload of the experts.

Generally, automated immunohistochemical (IHC) image analysis system consist of two

major subsystems: 1) tissue section preparation and image acquisition; 2) automatic
tissue image analysis, both involve a complex hardware and software elements [18].
Preparation of tissue section and image acquisition is a complex process that involves
sequence of chemical and mechanical procedures with highly sophisticated hardware
components. A brief introduction about various steps involved in immunostaining of oral
cancer tissue images, tissue section preparation and image acquisition using whole slide
imaging scanners are given in next sections.
Figure 4: IHC procedure from biopsy specimen to microscopic evaluation

5. Tissue section preparation and image acquisition

IHC is a technique widely employed in histopathology to detect targeted protein

expression in tissue sections by the use of labelled antibodies through antigen-antibody
interaction. In particular, the detection is achieved by staining the tissues with the
labelled antibodies, which have been selectively bound to the antigen under investigation.
Professors A.H. Coons, H.J. Creech and R.N. Jones from department of Bacteriology and
Immunology, Harvard Medical School and the Chemical Laboratory, Harvard University,
introduced this technique during 1941 to detect bacteria and later it became one of the
most powerful tools in diagnostic pathology [25] [26].

In digital pathology, IHC procedure is often used for localizing target antigen and also to
identify abnormal cells such as those found in cancer tissues. Prior to microscopic
evaluation of tissue images, IHC procedure contains two main steps namely, preparation
of tissue sections and immuno-staining. These two steps are carried out by means of a
complex chemical and mechanical procedure, which are having a great influence on the
quality of the tissue images and also the repeatability of IHC analysis outcomes. In
general, IHC workflow consists of the following steps namely; fixation, accessioning,
grossing, tissue processing and embedding, sectioning, staining and screening
interpretation and archive (Figure 4) [18]. Initially a portion of tissue is surgically
removed from the suspected area of tumor location of cancer patient for biopsy
verification and then the following procedures are carried out to visualize the antigen-
antibody interaction.
Step 1: Surgically removed biopsy-specimen is immersed in a fixative at the pathology
laboratory in order to ensure the preservation of cell morphology and tissue architecture.
Here depending on the imaging modalities and analysis method, different fixatives
(crosslinking, precipitant etc) or methods (immersion, heat fixation, etc) have been used.

Step 2: Once the tissue sample arrived, the details are entered into laboratory information
systems (LIS) in the accessioning room. In order to trace the status of each tissue sample,
a barcode label is given with each specimen.

Step 3: After fixation, the tissue specimen is visually examined during grossing step for
suspicious area which again requires microscopic investigation and then, these regions
are excised as tissue blocks.

Step 4: Tissue block is processed using formalin and is dehydrated for making ultrathin
sections before embedding in paraffin or plastic material.

Step 5: Embedded tissues are sectioned into thin slices and placed in a glass slides. Each
slide is given a unique barcode to retrieve the information about staining protocol for the
particular section.

Step 6: The main part of tissue preparation is staining procedure, which has been
performed in direct or indirect way. Direct method is processed with only one labelled
antibody, directly reacting with the antigen in the tissue sections. This method is rarely
used due to poor signal amplification. Indirect methods are commonly employed in IHC
staining; here, primary antibody reacting tissue section and a secondary antibody
counterstained with primary antibody in order to visualize the distribution of nuclei
architecture, resulting in aa higher sensitivity by greater signal amplification. Later, tissue
sections are treated by dehydration, clearing, mounted and cover slipped.

Step 7: The pathologist examines immuno-stained tissue sections under micro- scope for
screening and interpretation.

Step 8: The outcomes are updated to the oncologist for designing an appropriate therapy
for cancer patient.

Generally biomarkers i.e., proteins or target antigens are colored by differ- ent staining
technique to visualize/highlight the positive/negative cell nuclei or region of interest from
the background. In general, p53 positive cell nuclei are colored using Diaminobenzidine
(DAB) staining which is one of the most commonly used stain and it gives dark brown
color to biomarkers. And the hematoxyline (H) is used as a counterstain that gives blue
color to the nega- tive cells and others. Therefore tissue sections of oral cancer are stained
with H-DAB staining protocol to analyze p53 protein content for diagnosis [3].

6. Whole slide imaging techniques:

Digital pathology is the field by which histopathology tissue slides are scanned to
produce very high-resolution digital images using whole-slide imaging (WSI) devices
[27] [19] [28]. These digitized images are given to automated image analysis tool for
further processes such as segmentation, nuclei detection, feature extraction, feature
selection, classification and scoring. In the past, most of the pathology labs have shown
keen interest on digital processing and started their process using high resolution imaging
techniques. This could possibly achieved only through the advancement in microscopic
techniques as well as related hardware and software components. Lots of researchers are
constantly working towards the development of advanced digital technologies in
histopathology and relevant field that has made the possibility of widespread
accessibility, long time and easy preservation of tissue slides with considerable amount of
price. The growth in storage capacity, display technologies, processor speed, bandwidth
expansion and networking allows WSI more effective and practically more feasible for
extracting quantitative features from the tissue images which helps the pathologist to
perform their work. However, the transformation of diagnostic pathology from traditional
light microscopy to WSI technology has been slower as compared to radiology related
technology due to various reasons including investment cost, memory capacity, storage
of both glass slide as well as its high-resolution image.

Wetzel and Gilbertson have developed the first CAD system based on high- resolution
WSI imaging devices during 1999 (described in [29]). Since, the requirements for WSI in
the field of diagnostic pathology have steadily increased to improve the reliability and
reproducibility of diagnostic outcome [27] [30]. In General, WSI scanners consists of the
following components: illumination systems, optical microscopic devices, a precise
focusing equipment that places tissue slide image on a digital scanner, high-resolution
display, storage unit and software and hardware components, which handle the sequence
of operations performed during scanning process. The final output of WSI is a complete
digital virtual slide which can be freely viewed at any standard range of magnification
and also carry out the necessary operations by the experts. WSI technology provides
promising results compared to traditional light microscope by avoiding several limiting
factors such as poor image quality, low-resolution overview of tissue section, control of
slide navigation, and the excessive amount of time requires to review a slide [31]. In
addition, WSI systems can be easily accessed remotely by the pathologist at place on the
globe to give their opinion about the tissue under study and also helpful for the people
who are working in the area of both clinical as well as biomedical engineering to carry
out teaching and research activities.

7. Conclusion

Over the past few decades, an automatic histopathological image analysis has shown
tremendous growth in terms of both hardware and software with the help of advanced
computing techniques. Many researchers have been working in this field aiming to
develop efficient as well as reliable automatic techniques for diagnosing cancer that could
help the oncologists in designing therapy for a specific patient. The survival rate of
cancer patients could be increased only when the disease is diagnosed at early stage.
However, cellular and molecular studies about biomarkers protein in tissue sections have
shown promising results in diagnosis of cancer at early stage. In particular, biomarker
proteins such as p53, ki-67, p15 etc. are reportedly considered as the most popular
predictive markers for early stage of oral cancer development. IHC techniques are
generally employed to visualize the activation of these biomarkers by staining the tissue
samples which are taken from diseased patients. The marked anti- bodies are located at
sub-cellular locations, such as cell nuclei, membrane and cytoplasm, which needs to be
analyzed carefully for extracting meaningful quantitative information. However, the
presence and the status of the disease could be studied only through a high-resolution
microscope. After the introduction of high-resolution WSI technologies, histology image
analysis became popular and most of the clinical onco-pathological labs are showing
keen interest on digital pathology related products. In this paper, we have given a brief
introduction to oral cancer and different types of diagnostic techniques which include
man- ual procedures currently employed and the requirements of automatic image
analysis methods

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