Hindawi Publishing Corporation Pathology Research International Volume 2016, Article ID 6293795, 8 pages http://dx.doi.org/10.1155/2016/6293795 Research Article Evaluation of Various Nuclear Cytological Changes in Normal Buccal Mucosa and Peritumoural Area in Patients with Oral Squamous Cell Carcinoma Receiving Concomitant Chemoradiotherapy Sadia Minhas,1 Muhammad Kashif,2 andA.H.Nagi3 1 Department of Oral Pathology, Akhtar Saeed Medical and Dental College, Bahria Town, Lahore 54000, Pakistan 2Department of Immunology, University of Health Sciences, Lahore, Pakistan 3Department of Morbid Anatomy and Histopathology, University of Health Sciences, Lahore, Pakistan Correspondence should be addressed to Sadia Minhas; [email protected] Received 13 October 2015; Accepted 30 March 2016 Academic Editor: Elizabeth Wiley Copyright © 2016 Sadia Minhas et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To evaluate the role of serial cytological assay in calculating the nuclear response of contralateral normal buccal mucosa and peritumoural area of squamous cell carcinoma of oral cavity in patients receiving fractionated radiotherapy (RT) and chemotherapy. Materials and Methods. This prospective, nonrandomized study wasmprised co of 76 histologically confirmed cases of oral squamous cell carcinoma on cyclical chemoradiation treatment. Chemoradiosensitivity was evaluated using serial scrape smears taken before and after immediate exposure to CCRT, at 17th day of CCRT (mid of treatment), and at the end of treatment. The nuclear changes, such as multinucleation, micronucleation, karyorrhexis, karyolysis, nuclear budding, prominent nucleoli, and binucleation occurring in both irradiated cancer cells and contralateral normal buccal mucosa, had a statistically significant dose related increase with concomitant chemoradiotherapy ( < 0.05). Conclusion. We recommend regular use of serial cytological assay during CCRT as it may prove to be a valuable tool for assessment of chemoradiosensitivity and persistence of tumour/dysplastic cells after radiotherapy. 1. Introduction depends on patient general health, the size of tumour, and metastasis [4]. The radiation which is used for the treatment Globally, oral cancer is the eighth most common cause of of cancers is ionizing radiation because it produces ions in the cancer-related deaths, although many people are unaware cells of the tissue from where it passes. This can kill cells or of its presence [1]. Of these oral cancers, more than 90% alter genes so that the cells cannot grow [5]. are oral squamous cell carcinomas (OSCC) arising in the The drugs flow all-round the body in the blood and mucous membranes of the oral cavity, floor of the mouth, reach cancer cells nearly anywhere in the body. This is called ventral surface of the tongue, and oropharynx [2]. A study systemic treatment. Chemotherapy drugs deteriorate the conducted by Bhurgi in Pakistan, reported that it is the most genes inside the nucleus of cells. A combination of different common cancer in Pakistan, whereas Rehman and Jafferi chemotherapy drugs are used for the treatment of cancer. found that oral carcinoma constitutes about 10% of the malig- The combination of chemotherapy drugs damages cells at nanciesinPakistan[3].Theearlyoralcancersareusually different stages in the course of cell division. There is more treated with surgery and radiation therapy, whereas patients chance of killing more cells with the use of more than one with advanced oral tumours may undergo combination of type of drug [6]. A concurrent chemoradiotherapy (CCRT) treatments, that is, radiation therapy, chemotherapy, and regimen represents the most excellent current standard ther- concomitant chemoradiotherapy. The selection of treatments apy for many patients with regionally advanced solid tumours 2 Pathology Research International and improves the likelihood of cure. The clinical goal of entered and analyzed using the SPSS 20.0. The variation in the administrating chemotherapy and radiation concurrently is frequencyofthesechangesinrelationtocumulativeradiation to develop both locoregional and systemic tumour control dose was analyzed using Chi-square test/Fisher exact test and [7]. a value < 0.05 was considered as statistically significant. For oral cancer, cytology has been an option and proved The study was approved and certified by Institutional Ethical to be a consistent primary diagnostic test. It can also be of Review Committee and Advanced Studies & Research Board, value where surgical biopsy is not indicated or in postra- UHS Lahore, Pakistan. diotherapy follow-up cases. The combined histological and cytological assessment of a lesion has been found to give 3. Results the highest percentage of early diagnosis of oral cancers [8]. Cytological effects of radiation on oral mucosa and in oral In 304 smears from normal buccal mucosa on all respective cancers were reported in 1957 and 1959, respectively [9]. days of CCRT, karyolysis was seen in = 156 (51.3%) smears Numerous reports have described different cytoplasmic and and it was absent in = 148 (48.7%) smears. Out of 76 smears nuclear changes following radiation therapy. These changes from normal buccal mucosa on each day, that is, before and consist of cytoplasmic granulation, cellular enlargement, vac- immediately after first dose, at 17th day, and at end of CCRT, uolization, pyknosis, binucleation, karyorrhexis, karyolysis, karyolysis was seen in =1(1.3%), =3(3.9%), and =76 micronucleation, nuclear budding, nuclear enlargement, and (100%)for17thdayandendoftherapysmears,respectively.In multinucleation [10]. overall 304 smears from peritumoural area on all respective By the 1960s, the nuclear morphological alterations that days of sampling, karyolysis was seen in = 180 (59.2%) were calculated by cytology became well established and smears and it was absent in = 124 (40.8%) smears. included karyorrhexis, karyolysis, multinucleation, and cre- Considering the karyolysis in peritumoural area before nation of nuclear membrane [11]. Despite a high incidence and after immediate exposure to CCRT it was seen in =7 of oral cancer in Asian region, studies on prediction of (9.2%) and =21(27.6%) smears, respectively. Smears were effectiveness of various treatment modalities are inadequate takenoneachday,thatis,atthe17thdayandattheendof and sparse, in this region [12]. The present study was therapy; all the smears (100%) were positive for karyolysis. taken forward to see whether serial cytological evaluation Destructive fragmentation of nucleus (karyorrhexis) in from normal buccal mucosa and peritumoural area in oral normal buccal mucosal cells on all particular days of treat- squamous cell carcinoma patients receiving concomitant ment from 76 patients was observed in = 154 (50.6%) chemoradiotherapy at four different stages can predict the smears and absent in = 150 (49.3%) smears. Among 76 chemoradiosensitivity of peritumoural area and response of smears from normal buccal mucosa on all sampling days, normal buccal mucosa. that is, before and after immediate exposure, at 17th day, and at end of CCRT, karyorrhexis was observed in 1.3%, 2.6%, 2. Materials and Methods 98.7%, and 100% smears, respectively. The study was conducted in Department of Morbid Anatomy While inspecting the 304 smears from peritumoural area on all specific days of CCRT, karyorrhexis was seen in and Histopathology, University of Health Sciences Lahore = 174 = 130 Pakistan, during the period of one year. A total of 76 patients (57.2%) smears. In (42.7%) smears no with histologically proven squamous cell carcinoma of oral karyorrhexis was seen in peritumoural area. Out of 76 smears cavity, on fractionated radiotherapy on a dose of 70–90 Gy from peritumoural area on each day, that is, before CCRT =7(9.2%), after immediate exposure =15(9.7%), at in 5 fractions/week for a span of 7 weeks (total 35 fractions), =76 were included in the study. Scrape smears were collected 17th day, and at end of CCRT, (100%) of smears were from peritumoural area (the peritumoural area is defined as positive for karyorrhexis (Table 1). a 2 mm wide band of host tissue adjacent to the invasive Regarding binucleation in contralateral normal buccal front. The tumour periphery is defined as a 2 mm wide mucosal cells, it was present in = 190 (62.5%) out of band of tumour immediately adjacent to the invasive front, 304smearswhileitwasabsentin = 114 (37.5%) smears. and tumour center is defined as an inner center area) and A total of 76 smears from normal buccal mucosa before contralateralnormalbuccalmucosaofeachpatientbeforethe CCRT =7(9.2%), after immediate exposure to CCRT start, after immediate exposure to CCRT, on 17th day, and at =32(42.1%), at the 17th day of treatment 98.7%, and at the end of treatment. The cytological smears were obtained by the end of treatment =76(100%) smears were positive for scraping the peritumoural area and contralateral normal buc- binucleation (Figure 1). calmucosausingtheroundedendofAyre’sspatulaandslides Among all the 304 smears from peritumoural on all were fixed in 95% alcohol for haematoxylin and eosin and particular days of sampling, binucleation was observed in = Papanicolaou (Pap) stains, while some slides were air dried 263 (86.5%) and absent in =41(13.5%) smears (Figure 1). for May-Grunwald-Giemsa (MGG) stain. Smears were exam- On each