TOUCH IMPRINT CYTOLOGY: A RAPID

AND ACCURATE METHOD FOR

DIAGNOSIS OF ORAL CANCER

ORIGINAL ARTICLE

Adhya AK, Kar M, Mohanty R. Touch Imprint

Cytology: A Rapid and Accurate Method for
Diagnosis of Oral Cancer. Acta cytol 2019; 63: 411-
6.
INTRODUCTION
 Oral cavity cancers are very common in India.
 The most common histological type: squamous cell
carcinoma.
 Biopsy: preferred method of tissue diagnosis to confirm
malignancy in suspected cases.
 Delay (3–7 days) in obtaining a tissue diagnosis
• unnecessary apprehension among the patients
• delay in the definitive workup and treatment of patients.
 Touch imprint cytology (TIC): simple, cheap, and can be used
as a rapid method of tissue diagnosis.
 Uses:
• Adjunct to frozen sections for the intraoperative diagnosis of
cancer
• Evaluation of surgical-cut margins
• Evaluation of sentinel nodes for metastasis
• Diagnosis of head and neck lesions
• Assessment of adequacy of CT/USG-guided core biopsies of
masses and impalpable breast lump
• Post-mortem tissue diagnosis
OBJECTIVE
 To study the utility of TIC as a preoperative diagnostic tool in
a large number of cases of oral squamous cell carcinoma
 The diagnostic accuracy and causes of false positivity and
false negativity were evaluated.
MATERIALS AND METHODS
 480 TIC cases of biopsies taken from various sites
 280 cases: clinically suspected oral squamous cell carcinoma.
 Biopsies include:
• Tongue (21%)
• Gingivobuccal sulcus (21%)
• Buccal mucosa (20%)
• Retromolar trigone (15%)
• Lower alveolus (13%)
• Upper alveolus (10%).
 Touch imprints: made by the surgeon immediately after obtaining
the incisional biopsy tissue by gently pressing the fresh unfixed
tissue to clean glass slides.
 Minimum: 4 imprint smears in each case (avoiding blood and
mucus).
 2 air dried (MGG) and 2 immediately fixed in isopropyl alcohol
for15–20 min (H&E, PAP).
 Staining and evaluation was done in lab adjacent to the outpatient
procedure room.
 Provisional report issued on the same day (within 3–5 hrs).
 The tissue was then put in formalin and submitted for routine
histopathological study.
ASSESSMENT OF TIC SMEARS
 Quality of preparation
 Degree of diagnostic accuracy
 Labelled as inadequate
• suboptimal cellularity
• distorted morphology
 Adequacy criteria: presence of at least 2 clusters of 10 cells
showing well-preserved cell morphology.
 The diagnosis given on the TIC were compared with the final
diagnosis made on the corresponding biopsy sections
CYTOLOGICAL RESULTS
(i) Malignant (the cellular findings are diagnostic of malignancy)
(ii) Suspicious for malignancy (suggestion of cancer but uncertain
due to the limited number of cells or the degree of atypia)
(iii) Negative for malignancy (no evidence of malignancy)
(iv) Unsatisfactory specimen (scant cellularity, air-drying or
distortion artefact, obscuring blood or inflammation).

 The overall sensitivity, specificity, PPV, NPV, and accuracy

evaluated by comparing them with the corresponding final
diagnosis given by biopsy sections.
 RESULTS
 Total cases: 280 of oral cavity lesions .
 The age range of the patients: 20 to 81 years (mean 58 years).
 Adequate and satisfactory material on touch imprint: 277 (98.9%) cases.
 3 cases- inadequate for opinion (low cellularity or obscuration of the
cells by inflammatory cells) and were also excluded from the final
statistical analysis.
 On repeat biopsies from previously inadequate biopsy: 2/3 were found
inadequate on final biopsy sections (only inflammatory exudates and no
mucosal tissue).
 One of them was adequate later: technical problem of the execution of
this sample.
 201 (82.5%) cases: malignant
 22 (7.9%) cases: suspicious of malignancy
 54 (19.3%) cases as benign/negative on TIC.

 Sensitivity of TIC was 98.2%

 Specificity was 89.3%
 PPV: 97.3%
 NPV: 92.6%.
 The overall diagnostic accuracy of TIC: 96.4%
A true-positive case diagnosed as squamous cell carcinoma on TIC
and its corresponding biopsy confirmation

A true-negative case showing benign cytological appearances on cytology

and its corresponding biopsy featuring benign hyperplastic squamous
epithelium
 DISCUSSION
 TIC: first described by Dudgeon and Patrick in 1927.
• cheap and rapid method for the evaluation of biopsy material
• fairly accurate for the diagnosis of cancer.
•

 Kubik et al. studied the utility of TIC as an adjunct to core-needle

biopsies of tumors of various sites (lungs, liver, or prostate)
• Diagnostic accuracy-91%.

 Adhya and Mohanty: high rate of sensitivity (96.9%), specificity

(97.4%), and accuracy (97.1%) of TIC in the preoperative diagnosis of
cancer.
 280 cases of oral lesions evaluated.
 TIC smears obtained in each case, stained with MGG, H&E and
PAP stain.
 MGG: cytoplasmic character of cells
 H&E and PAP stain: nuclear character
 Repeat biopsy for unsatisfactory cases
 Thus, TIC evaluation helped assess the adequacy of biopsy and
prevented a delay in diagnosis due to inadequate material on
biopsy.
 False-positive cases 6 (2.17%):
• Final biopsy: inflammatory atypia of the squamous
epithelium near the edge of benign inflammatory ulcers

 False-negative cases 4 (1.44%)

• Biopsy showed verrucous carcinoma or minimally invasive
squamous cell carcinoma of very well-differentiated type
• The lack of significant nuclear atypia in the tumor cells
• One case showed intact benign squamous epithelium over a
carcinoma infiltrating within the subepithelium
False positive case showing nuclear atypia on cytology and its corresponding
biopsy showing ulceration and inflammation

False-negative case with their corresponding biopsy sections showing

verrucous carcinoma
 False-negative case with their corresponding biopsy showing very well-
differentiated microinvasive squamous cell carcinoma with minimal nuclear atypia

False-negative case with their corresponding biopsy showing squamous cell

carcinoma infiltrating the subepithelium with intact normal squamous epithelium
 This study indicate that TIC can be used as an adjunct to the biopsy of
oral lesions in routine practice

 Diagnostic accuracy of 96.4% of TIC in oral lesions makes it highly

acceptable as a tool for the preoperative diagnosis of oral cancer.

 In 22 (7.9%) cases, a diagnosis of “suspicious of malignancy” was

given on TIC.
• 21/22 subsequently found malignant.

 Thus, the category of “suspicious of malignancy” needed

• To allows the cytologist to raise the suspicion of malignancy in a mass
lesion that does not meet all TIC criteria for malignancy.
• It helps keep false-positive diagnoses near zero.
 CONCLUSION

 TIC of incisional biopsy specimens of oral lesions yields adequate and

satisfactory diagnostic material.
 Can be used routinely at the site of biopsy:
 Evaluate the adequacy of the material obtained,
 Ensuring timely diagnosis
 Preventing the need for repeat biopsy later.
 Rapid and fairly accurate diagnosis of malignancy.

 Hence, patients can be immediately counselled and prepared for

further workup without the need to wait for days to obtain tissue
diagnosis of biopsy material.
THANK YOU