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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 90-96

Study of effect of smoking on cytomorphometry of buccal mucosal cells among smokers in South Gujarat Region


1 Tutor, Department of Anatomy, Surat Municipal Institute of Medical Education and Research, Surat, Gujarat, India
2 Professor and Head of Department, Department of Anatomy, Surat Municipal Institute of Medical Education and Research, Surat, Gujarat, India

Date of Submission02-Jun-2020
Date of Decision02-Aug-2020
Date of Acceptance10-Sep-2020
Date of Web Publication15-Oct-2020

Correspondence Address:
Neeraj Master
Department of Anatomy, Surat Municipal Institute of Medical Education and Research Centre, Surat, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/NJCA.NJCA_33_20

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  Abstract 


Background: Tobacco consumption is the major cause of oral cancer. Early detection of cytomorphometrical changes in the buccal mucosa of smoker by the use of exfoliative cytology could help in picking early premalignant changes and thereby reduce morbidity in oral cancer patients. Aim: To assess and compare the cytomorphometrical changes in the buccal mucosa cells among smoker and nonsmoker group and assess these findings in smokers with a duration of exposure to smoking by dividing them as per pack year groups. Materials and Methods: This study was carried out on 51 male cases (Cigarette or Bidi smoking) and 51 controls as per the inclusion and exclusion criteria. For finding the effect of smoking exposure severity, smokers were divided into three groups based on pack year like Group 1 with pack year <5, Group 2 with pack year 5–10, and Group 3 with pack year >10. Sample was taken from the buccal mucosa and stained with Papnicoalaou stain. Images were analyzed by Image J software and nuclear area (NA), cytoplasmic area, and nuclear/cellular ratio (N/C ratio) data collected and analyzed. Results: There was a significant difference for the mean values of NA and N/C ratio in the buccal mucosa of smokers. Significantly increased NA and N/C ratio were found with increased pack year. Conclusion: Cytomorphometrical findings such as NA and N/C ratio are observed in increased severity in premalignant conditions such as leukoplakia. Hence, it is possible to pick up these findings earlier by noninvasive method such as exfoliative cytology, and it can be used as an adjunct tool for mass screening.

Keywords: Cellular/nuclear ratio, cytomorphometry, exfoliative cytology, nuclear area, pack year, smoker


How to cite this article:
Parmar ND, Master N, Gupta DS. Study of effect of smoking on cytomorphometry of buccal mucosal cells among smokers in South Gujarat Region. Natl J Clin Anat 2020;9:90-6

How to cite this URL:
Parmar ND, Master N, Gupta DS. Study of effect of smoking on cytomorphometry of buccal mucosal cells among smokers in South Gujarat Region. Natl J Clin Anat [serial online] 2020 [cited 2020 Nov 28];9:90-6. Available from: http://www.njca.info/text.asp?2020/9/3/90/298164




  Introduction Top


Smoking tobacco is the major cause of lung cancer, chronic obstructive pulmonary disease, peripheral vascular disease, and various throat and mouth cancers. Tobacco consumption habits in form of chewing (in the form of betel quid or khaini) and smoking (bidis and cigarettes) are the common causes of oral cancer. Epidemiological studies show that the risk of developing oral cancer is five to nine times greater for smokers than for nonsmokers.[1] Two thirds (2/3) of oral squamous cell carcinoma and 75% of head and neck cancer can be attributed to tobacco use and alcohol consumption.[2],[3]

Cancer is one of the most life-threatening diseases afflicting mankind. Cancer pattern in India reveals the predominance of tobacco-related cancers, which are amenable to primary prevention. Oral cancer is one of the top three cancers affecting the Indian population and affects mostly male.[4] Oral cancer is ranked the third-most common cancer in India leading to about 1, 30, 000 death due to tobacco-related oral cancer, and its incidence is rising in the past decades. At present, in India, oral cancer is ranked as fourth common type of malignancy found in male after lung, stomach, and liver malignancy. Cancers in males are mostly tobacco related.[5] Oral cancer exhibits the geographical variation among different countries of the world and also within the different regions of a country depending upon regional prevalence of risk factors such as tobacco use and alcohol.[6]

Oral cancer is preceded by precancerous changes such as leukoplakia and erythroplakia 15 years before invasive stage in patients. Prompt action taken at this precancerous stage may reverse the cellular changes.[4] Even though oral mucosa is an easy accessible site for examination, patients of oral cancers are presented at late stage leading to poor prognosis. Hence, it is required to have technique which can pick early precancerous change before its progression to carcinoma. Exfoliative cytology is a noninvasive technique involving microscopic analysis of buccal mucosal cells. It may be advantageous for the detection and intervention in oral cancer patients at very early stage. There are various studies show that cytomorphometrical findings obtained by an exfoliative cytology can be used as an early predictor of premalignant lesion of the oral mucosa.[7],[8],[9] The purpose of this study was to evaluate and compare the cytomorphometrical changes of the exfoliated buccal mucosal cells in smokers with the results obtained from nonsmokers and to find any correlation with the duration and frequency of smoking on the basis of pack year formula.[10]


  Materials and Methods Top


After taking institutional ethics committee permission, this study was carried out on 102 individual randomly selected from the tertiary care hospital. Out of 102 patients, 51 were controls (nonsmoker) and 51 were cases (smokers having a history of smoking Bidi or cigarette). Women were excluded from the study due to hormonal influence on result.[11]

Sample size was calculated by using OPEN EPI 3.0.3 software for smokers and nonsmokers as calculated from previous study.[12]

Where

Z1−β= power of the study = 95%

Zα/2 = level of significance = 5%

and got sample size

n = 102, n 1 = 51 (case/smoker), n 2 = 51 (comparison group/control/nonsmoker)

Cases (smokers) were 51 non anemic and nondiabetic male patients with clinically healthy mucosa and having only history of smoking and not received radiotherapy or chemotherapy in the last 1 month. Controls (nonsmoker) were consisted of 51 participants with no history of smoking and without any systemic illness/anemia and diabetes. All patients who were wearing denture, gone under chemo or radiotherapy, with bad oral hygiene, having malignant lesion, addicted to alcohol or other forms of tobacco were excluded.

Cases (smokers) were grouped as according to pack year formula to find total exposure to tobacco due to cigarette and Bidi.[10]

Pack year = Number of cigarettes per day × number of year smoked/20

Pack year = Number of bidis per day × number of year smoked/20 × 0.25

The cases (smokers) were divided into three groups as follows:

  • Group 1: Patients with pack year <5
  • Group 2: Patients with pack year 5–10
  • Group 3: Patients with pack year >10


All patients were explained in detail about procedure, and informed consent was obtained. Sample site of the buccal mucosa was dried with sterile gauze, and buccal mucosal cells were collected from the normal side of cheek by 3–4 times scrapping of mucosa with a new wooden spatula. Sample was spread on precoded clear glass slide and was further processed for rapid Papnicoalaou stain.[13] For cytomorphometrical changes, 1280 × 720 pixel digital images were taken with ×10 eyepiece and ×40 objective and images were projected onto the monitor through mounted photomicrography unit adapter.

Image analysis of 30 clearly defined cells in each slide was done using the Image J 1.47 image analysis software [Figure 1]. Only clearly defined cells with clear outline were measured, avoiding clumped or folded cells. The cells were viewed moving the slide from the left upper corner to the right, and then down to avoid measuring the same cells twice. For measurement of cells, the software was calibrated and scale setting was changed from square pixels to micrometers square (μm 2). The nucleus and the cell outline were traced using digital cursor on the screen, and the software automatically calculated cytomorphometric measurements such as cellular area (CA) and nuclear area (NA). The nuclear/cellular ratio (N/C ratio) was calculated manually. The mean values were obtained in square micrometers for area.
Figure 1: Cytomorphometric measurement of buccal mucosal cells by Image j (1.48) software (×10). Arrow shows enlarged nucleus in smoker (×40)

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Statistical analysis

The data of smoker group were further analyzed based on their subgroup according to pack year. For each criterion, mean and standard deviation values were calculated and were subjected to appropriate statistical test like Student's t-test and univariate analysis of variance test by the SPSS software version (SPSS Inc., USA) to assess cytomorphometric data between nonsmoker control group and smoker case group, as well as within smoker subgroup,. In between the subgroups of smoker based on pack year, further statistical analysis was done by applying Tukey-honestly significant difference post hoc test in significant parameters. Statistical significance and P value obtained from them were checked. If P > 0.05, then the difference is not statistically significant. If P < 0.05, then the difference is statistically significant.


  Results Top


[Table 1] shows that when total 51 smokers were divided according to pack year, 15 (29.41%) patients fall in Group 1 with pack year <5, 19 (37.25%) patients fall in Group 2 with pack year between 5–10 and 17 (33.33%) patients fall in Group 3 with pack year >10.
Table 1: Distribution of smokers (cases) as per pack year

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[Table 2] shows that there was statistically significant difference between nonsmoker and smoker for NA and N/C ratio but not for CA.
Table 2: Comparison of nuclear area, cellular area, and nuclear/cellular ratio among smoker and nonsmoker

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[Table 3] shows cytomorphometrical analysis among group based on pack year and shows that there was significant difference between the groups based on pack year for NA and N/C ratio but not for CA.
Table 3: Comparison of nuclear area, cellular area, and nuclear/cellular ratio among groups of smoker as per pack year

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[Table 4] shows that there was difference for NA between Groups 1 and 2, between Groups 2 and 3, and between Groups 1 and 3. In case of nuclear to CA ratio, difference was present between Groups 2 and 3 and Groups 1 and 3 but not between Groups 1 and 2.
Table 4: Comparison of cytomorphometrical variable between the groups of smokers based on pack year

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  Discussion Top


Cancer registries have showed that most oral cancers in India discovered at advanced stage and makes treatment options prolonged and expensive. Therefore, the National Cancer Control Programme has also placed its emphasis on prevention, early detection, enhancement of therapy facilities, and provision of pain and palliative care.[14] Although oral mucosa is an accessible site for examination, many patients of oral cancers are presented at very advanced stage making it one of the cancers with lowest 5-year survival rate.[15] Hence, the early diagnosis of oral cavity cancers is of immense value in the successful treatment of patients.

Oral cancer mostly occurs as a result of malignant transformation of a preexisting lesion such as leukoplakia, erythroplakia, and oral sub mucous fibrosis (Osmf).[16] Detection of high-risk oral premalignant lesions and intervention at premalignant stages might represent a success toward reducing the mortality and morbidity associated with squamous cell carcinoma.[17] Identification of an early premalignant lesion having potential to malignant transformation can improve scenario in the cancer control programme.[8] Histological findings present in the premalignant changes of oral mucosa are large and prominent nuclei, increased nuclear to cytoplasmic ratio, hyperchromatic nuclei, abnormal-shaped nuclei, and cells and increased mitotic activity.[18] Nuclear enlargement with the increased nuclear/cytoplasmic ratio, nuclear hyperchromatism, chromatin clumping with prominent nucleation, irregularity of nuclear membranes, bi-or multinucleation, and increased keratinization are known to be the most important signs of cellular atypia and indicate increased cellular activity in the squamous epithelium.[19]

Oral mucosa exhibits a rapid turnover of cells, and these exfoliated cells play an imperative role in the diagnosis of potentially malignant disorders. Oral cavity reflects the various events occurring in the body which is revealed by the cytomorphological and nucleomorphological variations in these exfoliated cells.[20] Exfoliative cytology is a rapid, easy and noninvasive method to find out cellular alteration in buccal mucosal cells. They can pick findings well before gross clinical lesion appear in patient. In present study, buccal mucosal cells are observed for cytomorphometrical changes in 51 smokers with healthy oral mucosa and compared with 51 nonsmoker having healthy oral mucosa.

In present study, we found that mean NA in control was 47.09 ± 5.97 and in cases was 62.32 ± 10.24. Mean CA amongst control and cases were 2185.90 ± 391.40 and 2136.53 ± 331.02 respectively. Mean N/C ratio in control and cases was 0.0219 ± 0.0030 and 0.0299 ± 0.0067 respectively. There was statistically significant difference between control and cases for NA and N/C ratio but not for CA.

As shown in [Table 5] that NA in smoker increase significantly in compare to control in the present study and also in studies described by Usta et al.,[21] Seifi et al.,[22] Goregen et al.,[23] Parmar et al.,[24] Shetty et al.,[25] and Babuta et al.[18]
Table 5: Comparison of cellular area, nuclear area, and nuclear/cellular area parameter between previous studies with the present study

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Usta et al.[21] also stated higher results of both AgNOR counts and nuclear morphometry in smokers which indicates significant cellular proliferation and suggested that it can be starting of process of enlarged nuclei of dysplastic cells. Seifi et al.[22] conducted study in cigarette smokers, warerpipe smokers and control, and found increased NA in both type of smokers than controls but more prominent finding in cigarette smokers so concluded that cigarette smoking is more toxic than water pipe smoking.

[Table 5] shows that in the present study, although CA was decreased, but it was not statistically significant. Same findings were found in the study of Babuta et al.[18] Parmar et al.,[24] and Shetty et al.[25] In the present study, nuclear to cellular ratio is significantly increased between smokers and nonsmokers[Table 5]. It is similar with studies of Babuta et al.[18] and Seifi et al.[22] which also showed same findings. In a study done by Parmar et al.[24] who has calculated cellular/nuclear ratio and found it has been statistically significantly decreased between smoker and nonsmoker indicating increased NA and decreased CA and concluded that this altered ratio is an earliest indicator of cellular alteration progressing to dysplastic changes. Ogden [12] had done study in 36 smokers and reported increased NA, increased nuclear/cytoplasmic ratio and decreased cytoplasmic area, and concluded influence of smoking on the buccal mucosa.

A study conducted by Ahmed et al.,[26] Nadaf et al.,[27] Hande and Chaudhary,[28] Nivia et al.,[29] and Singh M et al.,[30] in different groups comprising tobacco users, smokers, or patients of premalignant conditions such as leukoplakia and carcinoma with that of controls have also reported the findings of increased NA, decreased cytoplasmic area, and increased N/C ratio. Nivia et al.[29] and Hande and Chaudhary [28] have concluded from the study that as leukoplakia and oral squamous cell carcinoma produce definitive cytomorphometrical changes, exfoliative cytology can be used as an adjunct tool in the detection of these lesions. Ramaesh et al.[7] also reported the values of exfoliative cytology in early detection of malignancy by observing such findings in his study.

In the present study, we compared these cytomorphometrical findings in relation to exposure to smoking based on pack year formula by making three groups. We found that as exposure to smoking increase by pack year <5, 5–10 and >10, there was increase in NA of 50.31 ± 2.82, 61.24 ± 3.93, and 74.13 ± 4.30, respectively, which is statistically significant. However, there was no statistically significant difference found in CA findings of all three groups which were 2171.20 ± 369.24, 2141.00 ± 259.84, and 2100.94 ± 380.35, respectively. In case of nuclear to cellular ratio, there was gradual increase from 0.0239 ± 0.0047, 0.0291 ± 0.0043, and 0.0361 ± 0.0048 among group of pack year <5, 5–10, and >10 which is significant. These findings are similar to the finding of Hashemipour et al.,[31] Babuta et al.,[18] and Shetty et al.,[25] as shown in [Table 6].
Table 6: Comparison of cytomorphometrical findings depending on the subgroups of smokers between the present study with previous studies

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[Table 6] shows that all studies have documented significantly increased NA, decreased CA, and increased N/C ratio with an increased frequency of cigarette or increased duration of smoking.

Hashemipour et al.[31] showed same findings in smokers and opium addicts compared to nonsmokers and concluded that exfoliative cytology can be used as a diagnostic and preventive tool in oral premalignant lesions.

On further analysis of findings obtained in the present study, we found that there was difference for NA between Groups 1 and 2, between Groups 2 and 3, and between Groups 1 and 3. In case of nuclear to CA ratio, difference was present between Groups 2 and 3 and Groups 1 and 3 but not between Groups 1 and 2. Such findings were not documented in any other study.

The findings present in our study like increased in NA may be due to cellular adaptation mechanism acquired by cell in response to injury by tobacco due to increased nuclear DNA. These adaptive changes within cell nucleus progress to dysplastic change.[23] As tobacco exposure process enhance aging process, it results into decreased turnover of buccal cells and delayed cell division. However, in meanwhile, synthesized protein remain accumulated in nucleus leading to nuclear enlargement.[22] During aging process, there is degeneration of Golgi apparatus and mitochondria which can lead to decreased area of cells and these could be one of the reasons for decreased CA. Increased in nuclear/CA can be explained by increased in NA and decreased in CA and is possibly can be due to reflection of significant changes in the cell at morphologic level.

N-Nitrosonomicotine is a genotoxic carcinogen present in tobacco smoke which acts on keratinocyte and on entering to cell nucleus they are converted by cytochrome P450 and Glutathione S transferase into compound which cause altered cell proliferation and DNA damage and leading to the process of carcinogenesis.[32]

Studies have shown that hormonal changes can alter nuclear diameter and cytoplasmic diameter of female oral mucosa.[11] Hence, to eliminate such effects on our study, we have excluded females from the study. Nutritional deficiencies and studies in systemic disease like diabetes have shown similar results in cytomorphometry of buccal mucosa like smoker so we have excluded them from present study. Deficiencies of Vitamin B12 and folic acid retard the synthesis of DNA, which is the core substance of cell nuclei, and hence may alter the size of nucleus and cytoplasm.[33],[34],[35] Hence, findings present in the study are due to the effect of smoking only.

Exfoliative cytology is an easy procedure for detecting such changes at earliest possible level and may help in reducing progress toward oral cancer. It is an easy, safer, cheaper, noninvasive, and reproducible method for the examination of oral cytology. Although exfoliative cytology cannot replace other methods for the diagnosis, it is an adjunct to them as it can have high patient compliance due to noninvasiveness.

The present study highlights the use of oral exfoliative cytology as an effective tool in noninvasive screening of population under the risk of oral cancer as early oral cancers and precancerous lesions are often subtle and asymptomatic. Health-care professionals can be trained for this procedure for the early detection of subtle lesion. It can be a better option in all patients contraindicated for biopsy and also as a noninvasive procedure in follow-up cases of oral cancer. Even it can be useful as an educational tool in smoker for cessation of smoking and to teach hazards associated with smoking. Availability of exfoliative cytology at rural level can provide benefit to poor patients.

Future study detecting conversion of healthy oral mucosa into premalignant or carcinoma lesion in high risk group patients using cytomorphological and cytomorphometrical parameters as a screening test in large sample may be helpful. It may provide more insight about usefulness of exfoliative cytology as a screening procedure. It would be prudent to conduct further research work in this area and subsequent public health implication.


  Conclusion Top


The present study highlights the use of oral exfoliative cytology as an effective tool in non-invasive screening of population under the risk of oral cancer as early oral cancers and precancerous lesions are often subtle and asymptomatic. Health care professional can be trained for this procedure for early detection of subtle lesion. It can be a better option in all patients contraindicated for biopsy and also as a non-invasive procedure in follow up cases of oral cancer. Even it can be useful as an educational tool in smoker for cessation of smoking and to teach hazards associated with smoking. Availability of exfoliative cytology at rural level can provide benefit to poor patients.

Future study detecting conversion of healthy oral mucosa into premalignant or carcinoma lesion in high risk group patients using cytomorphological and cytomorphometrical parameters as a screening test in large sample may be helpful. It may provide more insight about usefulness of exfoliative cytology as a screening procedure. It would be prudent to conduct further research work in this area and subsequent public health implication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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