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  Table of Contents    
ORIGINAL ARTICLE  
Year : 2014  |  Volume : 57  |  Issue : 2  |  Page : 223-230
Colposcopy: Gynecological vision in viewing oral lesions


1 Department of Oral Medicine and Radiology, Government Dental College and Research Institute, Bangalore, Karnataka, India
2 Department of Gynecology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
3 Department of General Pathology, Bowring and Lady Curzon Hospitals, Bangalore, Karnataka, India

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Date of Web Publication19-Jun-2014
 

   Abstract 

Context: The diagnosis of malignant and potentially malignant epithelial lesions of the oral mucosa cannot be based solely on clinical findings. The histologic evaluation of a representative biopsy specimen thus becomes necessary. The site for biopsy however is always a subjective choice that sometimes raises doubts about its representativeness. So far, no simple and reliable method is available for the selection of the most appropriate area for biopsy. Colposcopy is helpful in the selection of these sites of epithelial dysplasia depending upon the vascular patterns. Aims: This study was planned to assess the role of Colposcopic examination in the selection of biopsy site in patients with varying grades of oral epithelial dysplasia at various sites. Settings and Design: One hundred and eighty patients between the ages of 30 and 60 years clinically diagnosed with leukoplakia and carcinoma buccal mucosa were included in the study. Materials and Methods: For each of the subjects, a thorough clinical examination followed by Colposcopic assessment was carried out for the selection of biopsy site from the involved mucosa. The histopathological findings were then compared in the two cases and results analyzed. Statistical Analysis Used: The statistical analysis was performed using a paired t-test. Results: In our study, sensitivity and specificity for the selection of biopsy site by Colposcopic examination was found to be higher for leukoplakia than for carcinoma buccal mucosa. Conclusions: It was concluded that Colposcopic examination was found to be significant in the selection of biopsy site for leukoplakia while clinical criterion was found to be more appropriate for carcinoma buccal mucosa cases.

Keywords: Colposcopy, epithelial dysplasia, histopathological, potentially malignant epithelial lesions, vascular pattern

How to cite this article:
Nayyar AS, Khan M, Bafna U D, Siddique A, Gayitri H C. Colposcopy: Gynecological vision in viewing oral lesions. Indian J Pathol Microbiol 2014;57:223-30

How to cite this URL:
Nayyar AS, Khan M, Bafna U D, Siddique A, Gayitri H C. Colposcopy: Gynecological vision in viewing oral lesions. Indian J Pathol Microbiol [serial online] 2014 [cited 2021 Apr 20];57:223-30. Available from: https://www.ijpmonline.org/text.asp?2014/57/2/223/134672



   Introduction Top


The incidence of premalignant lesions and oral cancers is steadily increasing globally. In spite of advancement in the early detection, there is seen increased mortality and morbidity related to oral cancers. [1] Each year, globally, there are 222,000 new cases of oral cancer diagnosed in men (5% of all cancer) and 90,000 new cases diagnosed in women (2% of all cancer). [2]

Angiogenesis is a term that implies the formation of new micro-vessels from differentiated endothelium. Tumor angiogenesis occurs by recruitment of endothelial cell precursor or by sprouting of existing capillaries as in physiologic angiogenesis. However, tumor blood vessels differ from the normal vasculature by having altered morphology which can be exploited for diagnosis and as a prognostic indicator. Dysplasia and carcinoma in situ herald invasive oral cancer, [3],[4] but carcinomas also occur in areas which were previously apparently normal (not dysplastic). [4],[5]

Carcinoma of buccal mucosa, in particular, deserves special mention with increased incidence because of numerous premalignant lesions and conditions seen predominantly in this part of oral mucosa, the most common being leukoplakia, attributed commonly to the quid habit in Indian population.

Clinical diagnosis of squamous cell carcinomas of the oral mucosa is not difficult when the lesion is obviously invasive or, when the patient experiences pain, functional limitation, or, regional lymphadenopathy. Conversely, it is more difficult to diagnose dysplasia and carcinomas mainly in potentially malignant epithelial lesions (PMELs). With the aim of improving the efficiency of these diagnoses, techniques are being developed to complement clinical examination and to facilitate the identification of early dysplastic changes and early carcinomas. [6]

At present, though there are simple chair-side methods including staining with toluidine blue and exfoliative cytology to aid the diagnosis of such changes, there is a high risk of false positives. [7] Moreover, the diagnosis of a dysplastic premalignant lesion of the oral mucosa cannot be based solely on clinical findings. Therefore, a supplementary biopsy with a histopathological examination of the lesion is necessary to establish a definitive diagnosis.

Though, biopsy with histopathological examination is still considered the gold standard in the diagnosis of oral cancer and precancerous lesions and conditions, the selection of the site for biopsy is the most important criteria to arrive at a correct diagnosis. But, as biopsy site is a subjective choice, it is possible that biopsy specimens are taken from unrepresentative sites of the lesion or, before the morphologic changes could be detected in it. Hence, "Biopsy site remains the most reliable criterion for the correct diagnosis".

Even experienced clinicians cannot easily select a representative site for biopsy. Toluidine blue may be used to identify a suitable site for biopsy, but studies have shown that the risk of false-positive staining with the dye might be as high as 30%. [7] Therefore, a technique for non-invasively detecting dysplastic changes or, helping the clinician choose the appropriate site for biopsy can save patients from multiple biopsies and allow a broader range of diagnoses which can aid early detection of oral cancers. [8]

Colposcopy (direct intra-oral microscopy) offers advantages in selecting the more representative sites for biopsy than routine clinical examination alone and is a simple, painless, chairside diagnostic method. [9] The accuracy of colposcopic examination for the detection of mucosal changes approximates between 70% and 98%. [10],[11],[12],[13],[14]

Various authors have tried to adapt gynecologic methods of examination to the oral cavity as there is similarity between the two types of mucosa. [13] Colposcopy is one such method used to observe the mucosa of cervix for premalignant and malignant changes. So far, a few studies have highlighted the value of Colposcopy (direct intra-oral microscopy) in the diagnosis of oral mucosal lesions. Hence, the study was planned to assess the role of Colposcopic examination in the biopsy site selection for leukoplakia and carcinoma buccal mucosa. The objectives of the study were to assess the feasibility of using Colposcopic examination for leukoplakia and carcinoma buccal mucosa; to compare the Colposcopic examination findings with clinical criteria for selection of biopsy site in carcinoma buccal mucosa and leukoplakia; to correlate the histopathological findings with Colposcopic findings and clinical criteria; and to assess the sensitivity and specificity of Colposcopic examination in selecting the biopsy site in carcinoma buccal mucosa and leukoplakia.


   Materials and methods Top


Source of data

The study was conducted for a period of 1 1/2 year from May 2010 to Dec 2011. The study group consisted of 100 cases of clinically diagnosed cases of leukoplakia which further included 60 homogenous and 40 non-homogenous leukoplakias and 80 cases of carcinoma buccal mucosa in the age group of 30-60 years.

Method of collection of data

Patients were selected according to the defined inclusion and exclusion criteria. Before selecting the patients for the study, details of the study were explained to the patients and written informed consent was obtained for inclusion in the study. Ethical clearance for the study was obtained before the commencement of the study.

Selection criteria

Inclusion criteria included clinically diagnosed cases of leukoplakia and carcinoma buccal mucosa. In case of leukoplakia of buccal mucosa, extensive lesions of the oral mucosa with dimensions more than 2 cm 2 cm was the selection criterion. Patients with leukoplakia and carcinoma buccal mucosa with secondary infection, patients with leukoplakia and carcinoma buccal mucosa having other systemic diseases and patients undergoing treatment for leukoplakia and/or carcinoma buccal mucosa were excluded from the study.

Methodology

A total of 180 patients, 100 leukoplakia cases and 80 carcinoma buccal mucosa cases were selected for the study based on inclusion and exclusion criteria. The significance of the number of samples was analyzed statistically before their inclusion into the study. For each of the subjects, a detailed case history and thorough clinical examination was carried out and, under good illumination, intra-oral examination of the lesion was performed. Inspectory and palpatory findings were recorded in a prepared proforma. Following clinical examination of the lesion, the most representative site of the lesion was selected for biopsy based on set clinical criteria for dysplastic changes in leukoplakia and carcinoma buccal mucosa.

Clinical criteria for selection of the biopsy site for leukoplakia included erythema, granular consistency and ulceration, while that for carcinoma buccal mucosa included erythema, induration and ulceration. The outline of the lesion was then marked with a black color pen and the biopsy site with a red color pen with the help of a grid placed on the buccal mucosa.

All the cases were then subjected to the Colposcopic examination. Before taking up the patients for Colposcopic evaluation, the normal Colposcopic findings were standardized based on the Colposcopic criteria. Colposcopic assessment was performed and the most representative site for biopsy was selected from the involved buccal mucosa depending on the Colposcopic criteria. All patients were subjected to routine blood investigations including haemoglobin percentage, bleeding and clotting times, random blood sugar level, total and differential leucocyte counts, and erythrocyte sedimentation rate haemoglobin percentage (Hb), bleeding time (BT), clotting time (CT), random blood sugar (RBS), total leucocyte count (TLC), differential leucocyte count (DLC) and erythrocyte sedimentation rate (ESR) before the routine biopsy for histopathological examination and punch biopsy after Colposcopic evaluation with 6 mm diameter under local anesthesia was performed. The biopsy specimen was immediately immersed in 10% neutral buffered formaldehyde solution and was coded. Later, it was embedded in paraffin by routine methods and subjected to histopathological examination.

Colposcopic examination

Following clinical examination, the mucosa was wiped with saline. After the mucosa was wiped with saline, abnormal epithelium appeared much darker than the normal epithelium [Figure 1]a and b]. Using the blue (or green) filter [Figure 2] and higher power magnification, abnormal vascular patterns were evaluated [Figure 3]a-e] with the help of a Colposcope. Then, 5% acetic acid was applied to the lesion for about 60 s. The grid was again placed on the buccal mucosa. The area estimated to have the most extensive cell changes based on Colposcopic criteria was selected for biopsy and the area of the biopsy site was marked on the grid with a green pen [Figure 2].
Figure 1: (a) Homogenous leukoplakia in the left buccal mucosa before biopsy. (b) Carcinoma buccal mucosa (nodular variety) in the left buccal mucosa before biopsy

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Figure 2: Placement of grid for selection of biopsy site (green color for Colposcopy and red color for clinical criteria)

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Colposcopic criteria included vascular pattern, inter-capillary distance, surface pattern, color tone and opacity as well as clarity of demarcation of the mucosal lesions. In the normal mucosa of the uterine cervix, two basic types of capillary networks can be seen with direct microscopy, i.e., Colposcopy: Hairpin capillaries [Figure 3]a] and network capillaries [Figure 3]b]. In areas of dysplasia and carcinoma in situ of the uterine cervix, a specific vascular pattern, punctation (previously called ground), is seen commonly. Punctation [Figure 3]c] is characterized by dilated, often twisted, irregular, hairpin-type vessels. Another pattern of the vessels in dysplasia is called mosaic [Figure 3]d]. If the vessels do not reach the epithelial surface but extend only partially into the epithelium, they appear as red lines as surrounding blocks of epithelium. The Colposcopic image resembles tiles of a floor. After application of acetic acid, this pattern is further accentuated because of acetowhiteness of the atypical epithelium, forming a honeycomb pattern. True mosaic vessels are usually seen in sharply demarcated areas. When it is difficult to describe the pattern of the vessels, the term atypical vessels [Figure 3]e] is used. 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 histopathological examination.
Figure 3: Vascular patterns seen in Colposcopy: (a) Hair pin capillary pattern in normal buccal mucosa, (b) Network capillary pattern in normal buccal mucosa, (c) Punctation vessel pattern in leukoplakia, (d) Mosaic pattern in carcinoma buccal mucosa, (e) Atypical vessel pattern in carcinoma buccal mucosa

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When the area selected for biopsy by clinical criteria and Colposcopy was superimposed (red and green area), then only one common biopsy sample was obtained. When two different areas were selected from the same lesion, two different areas that were marked with red and green pens [Figure 2] were biopsied and subjected to histopathological examination. Biopsy specimens were taken with a 6-mm punch and biopsy wounds were sutured and histopathological examination of the same was performed [Figure 4]a and b].
Figure 4: Histopathological findings of biopsy specimens for leukoplakia and carcinoma buccal mucosa: (a) Histopathological findings of biopsy specimen selected by Colposcopic examination for leukoplakia revealing hyperchromatic and slightly pleomorphic nuclei in the basal and para-basal cell layers of stratified squamous epithelium and (b) Histopathological findings of biopsy specimen selected by Colposcopic examination for carcinoma buccal mucosa revealing dysplastic epithelial cells with keratin pearl formation

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Histopathological procedure

All the biopsied tissue specimens were sent for histopathological evaluation. The biopsied tissue was immediately transferred to the bottle containing 10% buffered formalin solution. Hematoxylin and eosin staining was performed for the microscopic examination of the sections.

Comparison of the histopathlogical diagnosis obtained with routine clinical examination and direct intra-oral microscopy was performed and the data were subjected to statistical analysis.

Grid preparation

A printed graph on an over-head projector overhead projection paper (OHP) sheet was used as a grid for marking the biopsy site. Each lesion was measured and the grid was prepared to the approximate size of the lesion. The entire lesion was divided into 6 mm 6 mm squares on a transparent grid. The outline of the lesion was marked with a black-colored pen, the red-colored pen was used to mark the area of the biopsy site with clinical criteria and the green-colored pen was used to mark the area of the biopsy site performed with Colposcopic criteria.


   Results Top


The study group consisted of 180 cases of clinically diagnosed cases of leukoplakia (60 homogenous and 40 non-homogenous patients) and carcinoma buccal mucosa (80 patients).

Vascular pattern observed in cases: The distinct vascular patterns seen in patients have been presented in [Table 1], [Table 2].
Table 1: Vascular pattern seen in patients based on Clinical criteriae

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Table 2: Vascular pattern seen in patients based on Colposcopic criteriae

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Histopathological findings observed in the biopsy specimen obtained from clinical presentation in carcinoma buccal mucosa and leukoplakia cases: Out of 30 homogenous leukoplakia patients, histopathological report of 7 presented with well-differentiated squamous cell carcinoma, 5 cases revealed moderately differentiated squamous cell carcinoma, 7 cases, carcinoma-in-situ while 3 cases presented with severe epithelial dysplasia with 8 cases presenting with mild epithelial dysplasia with chronic inflammatory cell infiltration. Out of 20 non-homogenous leukoplakia patients, histopathological report of 5 presented with well-differentiated squamous cell carcinoma, 5, moderately differentiated squamous cell carcinoma, 2 cases, carcinoma-in-situ while 7 cases presented with severe epithelial dysplasia and 1 case presented with mild epithelial dysplasia with chronic inflammatory cell infiltration. In case of carcinoma buccal mucosa patients, 11 patients were diagnosed with well-differentiated squamous cell carcinoma, 4 patients with moderately differentiated squamous cell carcinoma, 7 patients, carcinoma-in-situ, 9 patients presented with severe epithelial dysplasia alongwith 9 patients who gave a picture of mild epithelial dysplasia with chronic inflammatory cell infiltration [Table 3].
Table 3: Histopathological picture seen in patients in case of biopsy specimens taken with the help of Clinical criteriae

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Histopathological findings in Colposcopically directed biopsy specimen in carcinoma bucccal mucosa and leukoplakia cases: The histopathological findings in Colposcopically directed biopsy specimen in carcinoma bucccal mucosa and leukoplakia cases have been presented in [Table 4]. Out of 30 homogenous leukoplakia patients, histopathological report of 2 presented with well-differentiated squamous cell carcinoma, 3 cases revealed moderately differentiated squamous cell carcinoma, 11 cases, carcinoma-in-situ while 1 cases presented with severe epithelial dysplasia with 13 cases presenting with mild epithelial dysplasia with chronic inflammatory cell infiltration. Out of 20 non-homogenous leukoplakia patients, histopathological report of 7 presented with well-differentiated squamous cell carcinoma, 5, moderately differentiated squamous cell carcinoma, 3 cases, carcinoma-in-situ while 2 cases presented with severe epithelial dysplasia and 3 cases presented with mild epithelial dysplasia with chronic inflammatory cell infiltration. In case of carcinoma buccal mucosa patients, 11 patients were diagnosed with well-differentiated squamous cell carcinoma, 5 patients with moderately differentiated squamous cell carcinoma, 2 patients, carcinoma-in-situ, 13 patients presented with severe epithelial dysplasia while 9 patients gave a picture of mild epithelial dysplasia with chronic inflammatory cell infiltration [Table 4].
Table 4: Histopathological picture seen in patients in case of biopsy specimens taken with the help of Colposcopic criteriae

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Out of the 30 homogenous leukoplakia patients subjected to clinical examination, 47% of the patients were correctly diagnosed to have dysplastic changes in the final histopathological examination while the percentage of patients correctly diagnosed to have dysplastic changes was found to be 87% in case of patients where biopsy sites were selected based on Colposcopic criteria [Table 5].
Table 5: Table depicting the percentage of patients correctly diagnosd with the clinical criteriae and colposcopic technique in case of Homogenous Leukoplakia patients

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In case of non-homogenous leukoplakia patients, the respective percentages found were 35% and 855 respectively for clinical criteria and Colposcopic technique [Table 6].
Table 6: Table depicting the percentage of patients correctly diagnosd with the clinical criteriae and colposcopic Technique in case of Non-Homogenous Leukoplakia patients

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In case of carcinoma buccal mucosa patients, 50% of the patients were correctly diagnosed to have dysplastic changes when finally biopsy was taken while it came out to be 85% in case the biopsy sites were selected based on Colposcopic examination [Table 7].
Table 7: Table depicting the percentage of patients correctly diagnosd with the clinical criteriae and colposcopic technique in case of oral squamous cell carcinoma patients

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Overall, the Colposcopic examination was found to have a superior edge than clinical criteria in selection of biopsy sites for the patients which enlightened the possible role Colposcopic technique can have to highlight the areas to be taken up for final biopsy by reducing errors of clinical examination where areas of hyperkeratinisation or, frank ulceration with secondary infections might lead to a largely confusing picture of chronic inflammatory cell infiltration in the lesions masking the underlying malignancy, more problematic in cases of well-enough pre-cancerous strategies where an aggressive intervention might save the patients from more dreaded mortality and morbidity rates. The statistically significant results obtained in the study further highlight the possible implications Colposcopic technique might have in the examination of such cases in the future [Table 8].
Table 8: Table depicting the over-all percentage of patients correctly diagnosd with the clinical criteriae and colposcopic technique in case of Leukoplakia (Homogenous and Non-Homogenous Leukoplakia included) and oral squamous cell carcinoma patients

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   Discussion Top


Oral squamous cell carcinoma is a well-known malignancy which accounts for more than 90% of all oral cancers. The overall 5-year survival rate of oral squamous cell carcinoma has not significantly increased in the last few years despite tremendous advancements made in the plethora of diagnostic and treatment modalities in the last 2-3 decades. Hence, the most important task is to establish an early diagnosis at the first stages of the disease. [15]

The present study aimed at assessing the vascular patterns by Colposcopic findings and selecting the biopsy site in leukoplakia and carcinoma buccal mucosa and compares the two methods, clinical criteria and Colposcopic examination for selecting the biopsy site.

Colposcopy is the gold standard of examining the cervix, vagina and vulva under magnification using a Colposcope, a lighted binocular microscope connected to a video monitor that magnifies the area of interest 6-40 times its normal size, under an external white light for illumination. The higher powers are often necessary to identify certain characteristic vascular patterns that may indicate the presence of more advanced pre-cancerous or, cancerous lesions suggesting of the changes that are typical of epithelial dysplasia. Various light filters are also available to highlight different aspects of the surface epithelium. Acetic acid and iodine solutions (Lugol's or Schiller's) can also be applied to the surface epithelium to improve visualization of abnormal areas. [9]

The main purpose of colposcopy is to detect intra-epithelial and early neoplasia of the cervix, vagina and vulva. Most of the times, however, a colposcopic examination is indicated as an integral part of every gynaecologic examination in concert with cytological examination to further investigate a cytological abnormality on  Pap smear More Detailss. [10],[11],[12]

In our study, the average age of patients with carcinoma buccal mucosa were in-between 51 to 60 years and there was seen a female predominance in this group whereas patients with leukoplakia were seen to be maximum in the age group of 41 to 50 years with a characteristic male predominance. This suggested the habit of quid to be more common in females and smoking more common in males. The findings of our study were consistent with the age and gender of the oral cancer patients reported by other studies by Silverman, [16] Neville [17] and Swango. [18] However, the proportion of females in our study was slightly higher than that of other studies because of nature of the sample.

The sensitivity and specificity values of the biopsy specimens taken with the help of clinical criteria for carcinoma buccal mucosa were in accordance with the previous studies [19] including the one reported by Lingen MW, Kalmar JR, Karrison TC, Speight PM [20] who reported similar findings in their study. Lingen, in his study, suggested the conventional oral examination (COE) using normal (incandescent) light as one of the standard method for oral cancer screening. A study by Fedele S [21] with 9 years randomized controlled trial also revealed that screening via visual examination of the oral mucosa under white light is effective in reducing mortality in individuals exposed to risk factors.

Simple visual examination, however, is well known to be limited by subjective interpretation and by the potential, albeit rare, occurrence of dysplasia and early oral squamous cell carcinoma within areas of normal looking oral mucosa. As a consequence, adjunctive techniques have been suggested to increase the ability to differentiate between benign changes of the mucosa from dysplastic/malignant changes as well as to identify areas of dysplasia/early oral squamous cell carcinoma that are not visible to the naked eye.

Ellen H Hopman, [22] in his study stated colposcopy as an effective tool for diagnosing cervical intra-epithelial neoplasia. It was suggested that micro-invasive carcinoma was suspected when mosaic, punctation and acetowhite epithelium was seen with a thick white epithelium that had a clear and elevated margin with an irregular surface contour and raised capillaries.

Devi Charan Shetty, [23] in his study, stated that the histopathological assessment of a biopsy specimen is regarded as the most reliable criterion for a correct diagnosis in cases of epithelial dysplasia; consequently the specimen must be taken from the most representative area of a suspicious looking lesion for increasing the diagnostic accuracy.

In our study, we used the vascular patterns described in the criteria for vascular changes given in Colposcopic literature for the selection of biopsy site which include vascular pattern, inter-capillary distance, surface pattern, color tone and opacity as well as the clarity of demarcation of the mucosal lesions. [22],[24],[25] Different grading and scoring systems have been devised for colposcopic examination. Some of the more commonly used criteria include the one given by Coppleson and co-workers; [26] the Combined colposcopic index proposed by Reid and Scalz; [27] and the grading system of Burke and Co-workers. [28]

The high sensitivity and specificity values of Colposcopic examination regarding the selection of biopsy sites in the study were similar to the previously reported studies including the one conducted by Goran W. Gynther [14] for assessing the value of Colposcopy in diagnosing the mucosal lesions and the one reported by Devi Charan Shetty [23] who correlated the relevance of tumor angiogenesis pattern with the histopathological results in oral epithelial dysplasia.

The results of Colposcopic findings are actually based on vascular and tissue changes. The capillary changes preceding tumor growth with the pattern of tumor angiogenesis are different from the usual neo-vascularization taking place during repair and regeneration processes. At a cellular level, various molecules such as vascular endothelial growth factor, basic fibroblast growth factor, and transforming growth factor alpha are implicated. Direct optical visualization of these patterns would be helpful in the early determination of the underlying pathology and also aid in marking out the site of biopsy. [29]

In the present study, we found that the biopsy specimens selected with Colposcopic criteria appeared to be more representative of the histopathological findings at least in certain cases than those selected with routine clinical examination (COE). The altered vascular patterns, in the initial stages of lesion progression, definitely helped with the correct selection of the biopsy site, which in turn helped us reach a more definitive diagnosis, thus avoiding false-negative results.

The results of Colposcopic findings are based on vascular and tissue changes. The capillary changes preceding tumor growth with the pattern of tumor angiogenesis are different from the usual neo-vascularization taking place during repair and regeneration processes. At a cellular level, various molecules such as vascular endothelial growth factor, basic fibroblast growth factor, and transforming growth factor alpha are implicated, but the clinical perceptibility of these altered vascular patterns is poor. Direct optical visualization of these patterns would be helpful in the early determination of the underlying pathology and also aid in marking out the site of biopsy. [29]


   Conclusion Top


This is a preliminary study that emphasized the selection of biopsy site using Colposcopic examination as a method to select the most representative sites of epithelial dysplasia in frank cancerous and potentially malignant epithelial lesions. In the present study, we found that the biopsy specimens selected with Colposcopy appeared to be more representative of the histopathological findings than those selected with set clinical criteria. The altered vascular patterns definitely helped with the correct selection of the site for biopsy, which in turn helped us reach a more definitive diagnosis thus avoiding false-negative results. However, further studies are required with larger sample sizes to conclude the results and also studies on the use of various staining methods compared with Colposcopic examination are recommended for selecting the biopsy site for carcinoma buccal mucosa and leukoplakia patients.


   Acknowledgments Top


The authors thank all the people who directly and indirectly contributed to the study.

 
   References Top

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Correspondence Address:
Abhishek Singh Nayyar
H. No. 44, New Friends' Colony, Model Town, Panipat - 132 103, Haryana
India
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DOI: 10.4103/0377-4929.134672

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Table 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 7], [Table 8]



 

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    Abstract
   Introduction
    Materials and me...
   Results
   Discussion
   Conclusion
   Acknowledgments
    References
    Article Figures
    Article Tables

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