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 Table of Contents  
ORIGINAL ARTICLE - EVALUATIVE STUDY
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 172-174

Lugol's iodine identifies dysplastic tissue in precancerous lesions: A clinical trial


Department of Oral and Maxillofacial Surgery, Al-Badar Dental College and Hospital, Gulbarga, Karnataka, India

Date of Web Publication17-Feb-2017

Correspondence Address:
Rajarshi Basu
C/O: Dr. Debasish Basu, Sarala Bhavan, P.O: Nabapalli, Barasat; Dist: North 24 Paraganas - 700 126, West Bengal
India
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DOI: 10.4103/2231-0746.200333

PMID: 28299253

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  Abstract 

Introduction: Intraepithelial dysplasia, or “invisible” precancerous lesions, provides a challenge for visualization to the surgical team. The prognostic relevance of dysplasia and carcinoma in situ at surgical margins is well documented.Materials and Methods: We evaluated the use of Lugol's iodine in visualizing the surgical margins of dysplastic tissue by an observational study of 100 patients having oral precancerous lesions between June 2013 and March 2016. Conclusion: Lugol's iodine is a simple, inexpensive, and apparently effective means of diagnosing and visualizing the surgical margins of the dysplastic tissue in oral precancerous lesions.

Keywords: Head and neck cancer, Lugol's iodine, oral dysplasia, oral precancerous lesions


How to cite this article:
Fatima S, Basu R, Hallur NH. Lugol's iodine identifies dysplastic tissue in precancerous lesions: A clinical trial. Ann Maxillofac Surg 2016;6:172-4

How to cite this URL:
Fatima S, Basu R, Hallur NH. Lugol's iodine identifies dysplastic tissue in precancerous lesions: A clinical trial. Ann Maxillofac Surg [serial online] 2016 [cited 2017 Jun 22];6:172-4. Available from: http://www.amsjournal.com/text.asp?2016/6/2/172/200333


  Introduction Top


Intraepithelial dysplasia, or “invisible” precancerous lesions, provides a challenge for visualization to the surgical team. The prognostic relevance of dysplasia is well documented.[1] Distinguishing between normal and dysplastic mucosa is a very difficult job, and often the undetected presence of such a lesion leads to its delayed treatment and exacerbation [Figure 1] and [Figure 2]. We describe staining technique to aid the process of diagnosis and visualization by describing its effectiveness in 100 clinical cases. Lugol's iodine was selected as the staining agent of choice because of its availability, ease of use, cost-effectiveness and widespread use by endoscopists in the identification of intraepithelial neoplasia in the esophagus.[2],[3] The mucosal surfaces of the oral cavity are histopathologically similar to the esophagus and therefore it is expected that Lugol's iodine would be equally beneficial in the identification of intraepithelial neoplasia of the oral cavity.
Figure 1: A precancerous lesion, histopathologically diagnosed as homogenous leukoplakia with ill-defined margins

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Figure 2: A precancerous lesion, histopathologically diagnosed as homogenous leukoplakia with ill-defined margins

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  Patients and Methods Top


A total of 100 patients with white patches in different sites of the oral mucosa were included in the clinical trial. All the patients included in the study were with a mean age of 45 ± 10 years. To determine the extent of the precancerous lesion, sites that could possibly show epithelial dysplasia adjacent to the lesion were irrigated with Lugol's iodine solution. The technique for topical application of an aqueous solution of Lugol's iodine is shown in [Table 1].
Table 1: Method of application of the Lugol's iodine staining technique

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A large area of the oral cavity is covered by parakeratinized stratified squamous epithelium. Cells of the intermediate and superficial layers contain glycogen in their cytoplasm.[4] Whereas, dysplastic and invasive cancer cells contain little or no glycogen. Iodine is glycophilic, and so the application of Lugol's iodine solution results in uptake of iodine in normal glycogen-containing epithelium and stains it mahogany brown or black [Figure 2] and [Figure 4]. Areas of dysplasia and invasive cancer do not take up iodine (as they lack glycogen) and appear mustard-yellow or saffron-colored [Figure 3] and [Figure 4].[5]
Figure 3: The same lesion after being stained with lugol's iodine solution. The margins of the lesion which appeared to be ill-defined become much more prominent after staining and hence assist the clinician to correctly estimate the size and extent of the lesion

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Figure 4: The same lesions after being stained with Lugol's iodine solution. The margins of the lesions which appeared to be ill-defined become much more prominent after staining and hence assist the clinician to correctly estimate the size and extent of the lesion

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The criteria for clinical diagnosis were (1) homogeneous leukoplakia: A predominantly white, uniform, and flat lesion, not able to be scraped, with a smooth, wrinkled, or corrugated surface that may exhibit shallow cracks;[6],[7] (2) nonhomogeneous leukoplakia: A predominantly white or red and white lesion with an irregular, nodular, or exophytic surface;[6],[7] (3) erythroplakia: A velvety red lesion with imprecise borders that could not be diagnosed as any other lesion;[6],[7] (4) reticular lichen planus: A predominantly white lesion with intertwining lines or striae that confer a lacy or annular appearance;[7] (5) erosive/ulcerated lichen planus: A predominantly red, irregular erosion or ulceration associated with a reticular form, especially in the peripheral region of the lesion and with pseudomembranes covering the ulcerated areas;[7] and (6) superficial ulcerations suspicious of malignancy: Localized, superficial lesions without invasion or loss of mobility of neighboring chronic tissues that do not heal after local treatment.

The study has been approved by the appropriate ethical committee of our institution in which it was performed, and subjects gave informed written consent to the work.


  Results Top


A total of 100 cases clinically diagnosed with oral precancerous lesions were taken up for the study. Lugol's iodine was chosen as the material of choice for staining due to its low cost, wide availability, and ease of use. Lugol's iodine successfully stained the normal nondysplastic tissue around all the 100 precancerous lesions, forming a well-demarcated margin. The demarcated margins in all the 100 lesions were clinically appreciable. This enhanced clinical diagnosis and enabled us to measure the size of the dysplastic area more accurately. The clinical diagnosis of the oral lesions analyzed, and the results of staining are presented in [Table 2].
Table 2: Clinical diagnosis of oral lesions and results of staining

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  Discussion Top


Precancerous (also referred to as “potentially malignant”) oral lesions involve the skin lining of the mouth (known as the epithelium) and may be at risk for transforming into oral cancer.[8] There is, however, a varied opinion to predict as to which lesions will transform and how long it will take. The frequency of dysplastic or malignant alterations in oral precancerous lesions has ranged from 15.6% to 39.2% in several studies.[8],[9],[10],[11],[12] Most of the earlier studies showed a risk of malignant transformation in the range of 3.6%–6.0%. However, several of the more recent studies have shown more alarming malignant transformation rates ranging from 8.9% to 17.5%.[13],[14],[15] Although the reason for these results is unclear, it may be due to a more restrictive definition of what is considered clinically a precancerous lesion and further underscores the seriousness of it.

The location of an oral precancerous lesion has a significant correlation with the frequency of finding dysplastic or malignant changes at biopsy. The same correlation stands true for the size and extent of the lesion. Therefore it becomes of detrimental importance to evaluate correctly the extent of these lesions. As proved in this study, Lugol's iodine can play a major role in demarcating the margins of the lesion thereby enabling the clinician to estimate the correct size and extent of the precancerous lesion leading to early diagnosis and better management of the patient.

Although most oral carcinomas have adjacent areas of epithelial dysplasia, some carcinomas may not evolve from epithelium with top-to-bottom dysplastic changes but rather arise from basilar keratinocytes. Silverman et al. monitored 257 patients with oral leukoplakia; 22 had a diagnosis of epithelial dysplasia, the remaining 235 had hyperkeratosis. Eight of the 22 (36.4%) with epithelial dysplasia developed carcinoma. The time from initial diagnosis of either epithelial dysplasia or hyperkeratosis to carcinoma ranged from 6 months to 39 years. In another study, reported by Lumerman et al., (15.9%) of 44 patients with oral epithelial dysplasia identified in a histopathological study developed carcinoma.[16],[17] Mean time from biopsy to cancer diagnosis was 33.6 months. The estimated median time for this progression depends on the histopathologic severity of the epithelial dysplasia: 58 months for mild, 38 months for moderate, and 12 months for severe.[18]


  Conclusion Top


We can, therefore, conclude that Lugol's iodine can play a major role in demarcating the margins of the precancerous lesions, thereby enabling the clinician to estimate the correct size and extent of the precancerous lesion leading to early diagnosis and better management of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Weijers M, Snow GB, Bezemer PD, van der Wal JE, van der Waal I. The clinical relevance of epithelial dysplasia in the surgical margins of tongue and floor of mouth squamous cell carcinoma: An analysis of 37 patients. J Oral Pathol Med 2002;31:11-5.  Back to cited text no. 1
    
2.
Inoue H, Rey JF, Lightdale C. Lugol chromoendoscopy for esophageal squamous cell cancer. Endoscopy 2001;33:75-9.  Back to cited text no. 2
    
3.
He S, Guo GM, Liu FX, Huang XP, Xu X, Cai Y, et al. Molecular analysis in combination with iodine staining may contribute to the risk prediction of esophageal squamous cell carcinoma. J Cancer Res Clin Oncol 2008;134:307-15.  Back to cited text no. 3
    
4.
Doyle JL, Manhold JH Jr., Weisinger E. Study of glycogen content and “basement membrane” in benign and malignant oral lesions. Oral Surg Oral Med Oral Pathol 1968;26:667-73.  Back to cited text no. 4
    
5.
Anatomical and pathological basis of visual inspection with acetic acid (VIA) and with Lugol's iodine (VILI). International Agency for Research on Cancer; 2006. Available from: http://www.screening.iarc.fr. [Last accessed on 2017 Jan 17].  Back to cited text no. 5
    
6.
Axéll T, Pindborg JJ, Smith CJ, van der Waal I. An international collaborative group on oral white lesions. Oral white lesions with special reference to precancerous and tobacco-related lesions: Conclusions of an international symposium held in Uppsala, Sweden, May 18-21 1994. J Oral Pathol Med 1996;25:49-54.  Back to cited text no. 6
    
7.
Onofre MA, Sposto MR, Navarro CM, Motta ME, Turatti E, Almeida RT. Potentially malignant epithelial oral lesions: Discrepancies between clinical and histological diagnosis. Oral Dis 1997;3:148-52.  Back to cited text no. 7
    
8.
Shafer WG, Waldron CA. A clinical and histopathologic study of oral leukoplakia. Surg Gynecol Obstet 1961;112:411-20.  Back to cited text no. 8
    
9.
Waldron CA, Shafer WG. Leukoplakia revisited: A clinicopathologic study 3256 oral leukoplakias. Cancer 1975;36:1386-92.  Back to cited text no. 9
    
10.
Pindborg JJ, Renstrup G, Poulsen HE, Silverman S Jr. Studies in oral leukoplakias. V. Clinical and histologic signs of malignancy. Acta Odontol Scand 1963;21:407-14.  Back to cited text no. 10
    
11.
Bánóczy J, Csiba A. Occurrence of epithelial dysplasia in oral leukoplakia. Analysis and follow-up study of 12 cases. Oral Surg Oral Med Oral Pathol 1976;42:766-74.  Back to cited text no. 11
    
12.
Feller L, Altini M, Slabbert H. Pre-malignant lesions of the oral mucosa in a South African sample – A clinicopathological study. J Dent Assoc S Afr 1991;46:261-5.  Back to cited text no. 12
    
13.
Bouquot JE, Whitaker SB. Oral leukoplakia – Rationale for diagnosis and prognosis of its clinical subtypes or “phases”. Quintessence Int 1994;25:133-40.  Back to cited text no. 13
    
14.
Silverman S Jr., Gorsky M, Lozada F. Oral leukoplakia and malignant transformation. A follow-up study of 257 patients. Cancer 1984;53:563-8.  Back to cited text no. 14
    
15.
Lind PO. Malignant transformation in oral leukoplakia. Scand J Dent Res 1987;95:449-55.  Back to cited text no. 15
    
16.
Lumerman H, Freedman P, Kerpel S. Oral epithelial dysplasia and the development of invasive squamous cell carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:321-9.  Back to cited text no. 16
    
17.
Kaugars GE, Burns JC, Gunsolley JC. Epithelial dysplasia of the oral cavity and lips. Cancer 1988;62:2166-70.  Back to cited text no. 17
    
18.
Richart RM, Barron BA. A follow-up study of patients with cervical dysplasia. Am J Obstet Gynecol 1969;105:386-93.  Back to cited text no. 18
    


    Figures

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

  [Table 1], [Table 2]



 

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   Abstract
  Introduction
  Patients and Methods
  Results
  Discussion
  Conclusion
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