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An Insight to Oral Epithelial Dysplasia

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An Insight to Oral Epithelial Dysplasia 10.5005/jp-journals-10001-1144 VarunREVIEW Rastogi ARTICLE et al An Insight to Oral Epithelial Dysplasia Varun Rastogi, Naveen Puri, Satyaranjan Mishra, Swati Arora, Geetpriya Kaur, Lalita Yadav ABSTRACT clinical and histological changes depicting dysplasia.4 The Oral dysplasia is a potentially precancerous lesion diagnosed histological findings of dysplasia therefore indicate no more histologically. While the risk of progression is associated with than a lesion has a statistically increased risk of malignant histological grade, it is currently impossible to predict accurately change, but cannot be used for confident prediction of which lesions will progress. Although most oral pathologists malignant change in any individual case. Clearly, studies of recognize and accept the criteria for grading epithelial dysplasia based on architectural and cytological changes, there can be potential biomarkers are needed in order to introduce more considerable interexaminer and intraexaminer variation in the objectivity.5 assessment of the presence or absence and the grade of oral epithelial dysplasia. This article reviews the alterations, criteria, ALTERATIONS IN DYSPLASIA different grading systems and the markers used for assessing the malignant transformation of epithelial dysplasia. Dysplasia refers to a series of subtle changes in cells signifying Keywords: Epithelial dysplasia, Atypia, Genetic, Epigenetic, that anaplasia will develop soon. Dysplasia is theoretically Grading, Biomarkers. reversible and therefore not yet malignant. Dysplasia is a How to cite this article: Rastogi V, Puri N, Mishra S, Arora S, premalignant change. It is a change at tissue level while atypia Kaur G, Yadav L. An Insight to Oral Epithelial Dysplasia. Int J is a change at cellular level. Dysplasia is reversible and Head Neck Surg 2013;4(2):74-82. therefore a controlled cellular alteration. When the underlying Source of support: Nil inciting stimulus is removed, the dysplastic alterations revert to normal. Conflict of interest: None The alteration in dysplasia includes genetic changes, INTRODUCTION epigenetic changes and surface alterations. The sum total of these physical and morphological alterations are of diagnostic The term ‘Dysplasia’ was introduced by Reagon 1958 in and prognostic relevance and are designated as precancerous relation to the cells exfoliated from lesions of the uterine changes. cervix. Dysplasia is an ominous premalignant change. In past, A genetic change involves complex process due to the epithelial dysplasia, epithelial atypia and dyskeratosis were interaction of the host (genetic factor) with carcinogens in used synonymously. The first change suggesting malignant the environment and includes activation of proto-oncogenes, transformation is dysplasia. Dysplasia (dys = abnormal/bad; inactivation of the tumor suppressor genes and inactivation plasia = growth) is defined as ‘A precancerous lesion of of the genomic stability genes. stratified squamous epithelium characterized by cellular Epigenetic refers to heritable changes in the gene atypia and loss of normal maturation and stratification short expression that occur without alteration in DNA sequence. of carcinoma in situ’. Pindborg (1977) defined epithelial CH Waddington in 1942 defined it as ‘The branch of biology dysplasia as the term used for ‘A lesion in which part of the which studies the causal interactions between genes and their thickness of the epithelium is replaced by the cells showing products which bring the phenotype into being’.6 Chemical 1 varying degree of cellular atypia’. Lumermann et al (1995) modifications to DNA and its associated proteins can alter defined epithelial dysplasia as ‘A diagnostic term used to gene expression without altering the DNA sequence whereas describe the histopathological changes seen in chronic the genetic aberrations change the expression by altering the 2 progressive and premalignant disorders of oral mucosa’. sequence of A-T and C-G. The presence of dysplastic areas in the epithelium of the Epigenetic changes involve modifications in the upper aerodigestive tract is believed to be associated with a activation of certain genes, but not the basic structure of DNA. likely progression to cancer. Dysplastic features of a stratified Additionally, the chromatin proteins associated with DNA squamous epithelium are characterized by cellular atypia and may be activated or silenced. This accounts for why the loss of normal maturation and stratification.1 There is support differentiated cells in a multicellular organism express only for the view that the more severe the dysplasia the greater the the genes that are necessary for their own activity. Epigenetic likelihood is of progression to malignancy.3 It has been changes are preserved when cells divide. Most epigenetic demonstrated that the accumulation of genetic and epigenetic changes only occur within the course of one individual alteration takes place during malignant development and in organism’s lifetime, but some epigenetic changes are the oral mucosa this is reflected by a series of well-defined inherited from one generation to the next.6,7 74 IJHNS An Insight to Oral Epithelial Dysplasia Two primary and interconnected epigenetic mechanisms Smith and Pindborg Method include DNA methylation and modification of histones. Also A scoring system based on a set of photographic standards RNA is intimately involved in the formation of a repressive was suggested in the late 1960s (Smith and Pindborg 1969): chromatin state. Smith-Pindborg criteria9 is listed in Table 2. They described The surface alteration includes cellular adaptations, a simple system for assessing epithelial dysplasia to produce reversible and irreversible changes. The reversible changes a numerical score or epithelial atypia index. Katz et al (1985)10 are reversible if causative factors are removed. If they persist, found the system to be of considerable value for purposes of dysplastic cells escapes normal homeostatic control and standardization and eliminated observer bias by the use of assume the autonomy of tumor cells. The irreversible changes standard photographs. They evaluated 13 histological is characterized by accelerated cell division, which facilitates features which were standardized by a set of photographs. accumulation of genetic damage and further drives toward Each feature was graded ‘absent’, ‘slight’ and ‘marked’ path of transformation and lead to cell death or neoplastic as follows: transformation. Grading CRITERIA FOR DYSPLASIA Epithelial dysplasia index is the sum of 13 scores. Each feature When architectural disturbance is accompanied by carries a weighted score like basal cell hyperplasia = 4 and cytological atypia (variations in the size and shape of the marked pleomorphism of cells and nuclei = 6. A grading of keratinocytes) the term dysplasia applies. ‘none’ was scored 0 (zero). Grading of ‘slight’ or ‘marked’ 3 Criteria used for diagnosing oral epithelial dysplasia are was scored from 1 to 10. listed in Table 1. These features could be broadly categorized • The grading finally was done as follows: as changes to the architecture (strata) of the epithelium and Total score (EDI) Grade those that manifest as cellular atypia (Figs 1 to 9).3 • 0-10 Not dysplastic • 11-25 Mild dysplasia GRADING OF DYSPLASIA • 26-45 Moderate dysplasia • 46-75 Severe dysplasia Many dysplastic features in varying combinations have been The drawback is that the system relies on the weighting used for grading. However, difficulties have been of the individual criteria originally made by the authors and, encountered in assessing and standardizing the different therefore does not solve the problem of subjectivity. The degrees of epithelial dysplasia. Many systems of grading system is rather laborious and has not gained wide use for epithelial dysplasia have been proposed in order to routine diagnostic purposes. Warnakulasuriya (2001)11 standardize the severity of dysplastic features. In addition, commented on this system and noted that even inflammatory the parameters considered in the histological assessment or reactive lesions which are considered non-neoplastic may should be biologically meaningful, reflecting the malignant show some features of dysplasia. potential of the lesion.8 The various grading systems put forth by different authors are as follows: Mehta et al (1971) 1. Smith and Pindborg photograhic method (1969) 2. Mehta et al (1971) Mehta et al diagnosed epithelial dysplasia when two or more 3. Bancozy and Csiba (1976) features of Smith–Pindborg criteria were present. 4. WHO (1978) 12 5. Kramer (1980) Bancozy and Csiba (1976) 6. Burkhardt and Maerkar (1981) They diagnosed epithelial dysplasia using the following 7. Shafer (1983) criteria: 8. Lumermann H et al (1995) • Irregular epithelial stratification 9. Neville et al (1995) • Increased density of the basal cell layer or prickle cell 10. Speight PM et al (1996) layer or both 11. Kuffer and Lombardi (2002) • Increased number of mitotic figures 12. Ljubljana (2003) • Increased nuclear cytoplasmic ratio 13. Brothwell DJ (2003) • Loss of polarity of cells 14. WHO system (2005) • Nuclear pleomorphism 15. Binary system (2005) • Hyperchromatism International Journal of Head and Neck Surgery, May-August 2013;4(2):74-82 75 Varun Rastogi et al Table 1: Criteria used for dysplasia Architectural/tissue changes Cytological changes Irregular epithelial stratification Abnormal variation in nuclear size (anisonucleosis) Loss of polarity of basal cells Abnormal variation in
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