|Year : 2023 | Volume
| Issue : 1 | Page : 80
Evaluation of copper salivary level in oral squamous cell carcinoma, occupationally copper exposed, and its normal population and its association with cytomorphologic changes of oral mucosa
Nakisa Torabinia1, Arezoo Aghakouchakzadeh2, Neda Kargahi3, Alireza Motamedi4
1 Department of Oral and Maxillofacial Pathology, Dental Materials Research Center, School of Dentistry, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Oral and Maxillofacial Pathology, School of Dentistry, Alborz University of Medical Sciences, Karaj, Iran
3 Department of Oral and Maxillofacial Pathology, Dental Research Center, School of Dentistry, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
4 Otorhinolaryngologist, Isfahan, Iran
|Date of Submission||16-Jan-2023|
|Date of Acceptance||25-Apr-2023|
|Date of Web Publication||25-Jul-2023|
Dr. Neda Kargahi
Department of Oral and Maxillofacial Pathology, Dental Research Center, School of Dentistry, Dental Research Institute, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
Background: Oral squamous cell carcinoma (SCC) is one of the most common malignancies in oral cavity. Hence, presenting methods for early diagnosis and find the etiologic factors of oral SCC are important. Saliva analysis can be used to discover various conditions because of its noninvasive methods. Copper as a useful metal has been used by men since ancient times. The level of copper increases when the cancerous changes occur in addition to biopsy, an alternative method for examining oral lesions is exfoliative cytology. The primary objective of this study was to determine the salivary copper level and cytomorphologic changes of oral mucosa among three study groups.
Materials and Methods: This cross-sectional study included 15 individuals with oral SCC, 15 workers exposed to copper, and 15 healthy individuals. Saliva samples were collected and analyzed by atomic absorption spectrophotometer. The exfoliative smears were prepared by brush biopsy and stained by Papanicolaou and argyrophilic nucleolar organizer region (AgNOR) staining methods. Data analysis using one-way ANOVA and Kruskal–Wallis test. P < 0.05 was considered significant.
Results: There was a significant difference in mean salivary copper (P = 0.008), cytomorphology of oral mucosa, and AgNOR among the three groups (P < 0.001).
Conclusion: The results suggested that occupational exposure to copper increases the salivary levels of this element and causes changes in mucosal cells. Since this increase was very high and evidence of nuclear activity was seen in this group and in oral SCC patients, exposure to copper should be considered an important risk factor for oral mucosal changes.
Keywords: Copper, cytology, saliva, silver nitrate staining, squamous cell carcinoma
|How to cite this article:|
Torabinia N, Aghakouchakzadeh A, Kargahi N, Motamedi A. Evaluation of copper salivary level in oral squamous cell carcinoma, occupationally copper exposed, and its normal population and its association with cytomorphologic changes of oral mucosa. Dent Res J 2023;20:80
|How to cite this URL:|
Torabinia N, Aghakouchakzadeh A, Kargahi N, Motamedi A. Evaluation of copper salivary level in oral squamous cell carcinoma, occupationally copper exposed, and its normal population and its association with cytomorphologic changes of oral mucosa. Dent Res J [serial online] 2023 [cited 2023 Oct 1];20:80. Available from: https://www.drjjournal.net/text.asp?2023/20/1/80/382133
| Introduction|| |
Head-and-neck squamous cell carcinoma (SCC), which involves oral cavity, oropharynx, and hypopharynx, is the fifth most commonly occurring cancer in the world and is one of the most frequent causes of death in humans. SCC usually arises from a dysplastic mucosa, but dysplastic criteria and early invasive SCC grading are discussable. Several etiologic factors, such as the use of tobacco (smoking and nonsmoking), occupational exposure, environmental pollutants, dust and particles of metals, sunlight, vitamin deficiencies, hot foods, and bacterial and viral infections, have been identified for SCC., Several studies have investigated the role of occupational exposures in the occurrence of head-and-neck cancer.
Copper is one of the most useful metals, mined and worked by men since ancient times, because of its essential use in various spheres of life. The level of copper increases significantly when cancerous changes occur in the body. Ceruloplasmin of serum, which is the main protein of copper, rises four to eight times during malignancy. Workers exposed to melting, welding, cutting, or casting copper are also involved with this element.
Recently, saliva analysis had been adverted due to its simple, noninvasive collection, and low-cost storage methods. Oral fluid sampling is safe for the operator and patient.
These days, exfoliative cytology as an alternative method for oral lesions examination is simple, noninvasive, and inexpensive and can be used to conveniently identify biomarkers in laboratories. It is routinely done in medical and dental offices, which may increase the early diagnosis of oral mucosal malignancies in clinical trials. Changes in surface epithelium cells can be reserved in nuclei and it would be a real marker for dysplastic or neoplastic changes.
Papanicolaou (PAP) staining is a common method used for cytology analysis and allows it to identify primary inflammation, dysplastic, or malignant changes.
Over time, the ability of other staining methods and markers to enhance the reliability of exfoliative cytology has been investigated, one of which is silver nitrate staining (argyrophilic nucleolar organizer region [AgNOR]). This technique uses nuclear organizer regions (NORs) as an indicator for the diagnosis of various cancers. These particular portions of DNA are associated with nonhistone, argyrophilic, and acidic proteins. NORs are seen by staining under the optical microscope as the black spots on the nucleus. Given the close relationship between NORs and cellular activity, the size and number of NORs can reflect or predict cell proliferation, transformation, or malignancy. Malignant tumor cells show large numbers per nucleus along with small size, scattered distribution, and an irregular shape of AgNOR. However, a small number of AgNORs per nucleus as well as large size, clustered distribution, and roundness are observed in benign tumor cells.
The aim of this study was to determine the level of salivary copper and cytomorphologic changes of oral mucosa in patients with oral SCC, healthy people, and people with occupational exposure to copper.
| Materials and Methods|| |
In this cross-sectional study, 15 individuals with oral cancer, 15 workers exposed to copper (workers of the copper melting factory who had at least 5 years of work experience), and 15 healthy volunteers in dental school (control group) were included in the study. The participants were asked to wash their mouths with a physiological serum before starting saliva collection. Then, each individual sat in a comfortable position starting the saliva collection with open eyes, bending slightly forward, and evacuating 5 ml of saliva in the test tube. The specimens were then stored at −20°C and sent to the laboratory for evaluation of salivary copper. After the oral examination, using a disposable cytobrush on the mucosa (in the healthy group and workers, from the buccal mucosa and oral SCC from the lesion area), the cell samples were collected and transferred to a clean and dry slide. Before drying, the specimens were fixed immediately by Pathofix spray (Iran's antibacterial medicine company), which contains 95% ethanol. Then, the slides were stained separately by PAP and AgNOR.
Saliva samples were analyzed by atomic absorption spectrophotometer, and the results were expressed as micrograms per liter (μg/L). The PAP-stained slides were analyzed under a microscope (Olympus BX41TF, Tokyo, Japan) at (×100) magnification, and the parameters mentioned in the smears were analyzed and grouped. The parameters analyzed in the smears by PAP stain included large nuclei, nuclear changing in size and shape, pleomorphism, nuclear borders, nucleus-to-cytoplasm ratio, number of nuclei, and hyperchromatism. Dysplastic changes were registered and grouped in sequence:
- Class I: Normal
- Class II: Atypical
- Class III: Indeterminate
- Class IV: Suggestive of cancer
- Class V: Positive for cancer.
- Then, the AgNOR-stained slides were evaluated for NOR count. In each slide, several cells were explored at (×100) magnification, and one cell was randomly selected. The brown–black spots in the nucleus were counted. The interconnected and nucleolus points were considered one point. The areas of necrosis, severe inflammation, and artifacts were not calculated. Data were analyzed by one-way ANOVA, Tukey's test, Kruskal–Wallis test, and Mann–Whitney test, and P < 0.05 was considered significant.
This study has been approved by the Research and Ethics Committee of Isfahan University of Medical Sciences by No: 396089.
| Results|| |
One-way ANOVA showed a significant difference in mean salivary copper (P = 0.008) and AgNOR (P < 0.001) among the three groups [Table 1] and [Figure 1]. Tukey's test showed that the mean amount of copper was significantly higher in the workers' saliva workers than in those with oral cancer (P = 0.001), and it was significantly higher in oral SCC patients than in the control group [P = 0.04, [Diagram 1]]. The average number of AgNOR was significantly higher in oral SCC patients than in workers (P < 0.001) and was significantly higher in workers than in the control group [P < 0.001, [Diagram 2]].
|Table 1: Average salivary copper with μg/L and Ag nucleolar organizer region count in three groups|
Click here to view
|Figure 1: Argyrophilic nucleolar organiser region stain (×100) (a) Control group, (b) Worker, (c) Oral squamous cell carcinoma patient.|
Click here to view
Kruskal–Wallis test showed that the cytomorphology of oral mucosa was significantly different between the three groups (P < 0.001). To compare the cytomorphology of oral mucosa between two groups, Mann–Whitney test was used. This test showed that oral mucosal cytomorphology classes were significantly higher in people with oral SCC than in workers (P < 0.001) and in workers was significantly higher than in the control group [P < 0.001, [Table 2] and [Figure 2]].
|Table 2: Frequency distribution of oral mucosa cytomorphology classes with Papanicolaou staining in three groups|
Click here to view
|Figure 2: Papanicolaou stain (×100) (a) Normal cells (Class I), (b) Atypical cells (Class II), (c) Indeterminate cells (Class III), (d) Positive for cancer (Class V).|
Click here to view
| Discussion|| |
Oral SCC involves half of the oral cavity malignancies and is one of the major health problems in developing countries that leads to death.
Several factors are involved in the development of oral SCCs, including lifestyle and environmental factors. However, efforts have been made by clinical epidemiologists to illustrate the link between malignancies and scarcity or excessive presence of rare elements.
Some evidence and studies have shown that long-term exposure to an average amount of copper, as in various occupational environments, affects people's health. Moreover, some studies have reported a positive relationship between copper levels in the serum, saliva, and malignancy outbreak.,
In this study, the copper level in saliva and cytomorphological changes in the oral mucosa of subjects with occupational exposure to copper in comparison with healthy people and those with oral cancer were evaluated using exfoliative cytology and AgNOR staining.
The salivary copper level in this study showed a significant difference between the three groups. It was 1215.5 in the workers, which was higher than normal and oral SCC patients. However, it was higher in people with SCC 143.3 than in healthy individuals 31.5.
Several studies have investigated the serum copper level in various oral, head, and neck lesions, but few studies have examined the salivary copper level in patients.
Al-Rawi and Talabani reported that the salivary levels of copper and iron were higher in malignant individuals than in healthy people. Ayinampudi and Narsimhan also showed a significant difference in the salivary copper level in malignant and premalignant oral lesions.
The results of this study were along with those of the above studies, indicating that the amount of salivary copper increased when malignancy occurred. Although it cannot be argued with certainty that this increase is a secondary response to malignant changes or the patients; for some other reasons, had increased levels of salivary copper before malignancy occurrence. This increase stimulates the proliferation of endothelial cells and plays an important role in angiogenesis, which can be effective in the process of malignancy. Hence, increasing salivary copper content in the workers exposed to this element needs special consideration. Although saliva was easily accessible and could reflect the presence of rare elements in the body, in this study, salivary levels of copper were investigated using a precise method, atomic absorption.
The results of the exfoliative cytology evaluation showed a significant difference among the three groups. The exfoliated cells in patients with SCC were classified as Class V, which were positive for malignancy and showed malignant diagnostic criteria. Cellular changes in the oral mucosa of workers were significantly different from those in normal people. In this group, the cells showed atypical changes (Class II) and intermediate changes (Class III), while in the healthy people group, all cells were normal (Class I) without any changes.
In 2014, Gonzalez Segura et al. examined the relationship between PAP staining and cytomorphometric analysis in exfoliative cytology of oral mucosa and observed that these methods had high accuracy in the diagnosis of malignancy.
Verma et al. (2015) conducted a study to evaluate the usefulness of this method in the diagnosis of oral malignant lesions and observed that assessment of changes in the nucleus and cytoplasm by cytomorphometry could be utilized as a very useful complement in the diagnosis and prognosis of dysplastic lesions which could be transformed to malignancy.
The results of this study by this method were in agreement with those of previous studies. Cellular changes that have been made and their transformation from normal to atypical and intermediate cells can indicate the effects of copper on these cells, which requires a special follow-up despite the absence of clear tissue changes.
The mean number of AgNOR showed a significant difference between the three groups. The mean number of AgNORs in oral malignant lesions was 8.8, which was significantly higher than that of the workers with a mean of 4. In the normal group, the mean number of AgNOR was 1.9, which was significantly lower than those of the other two groups.
In a similar study in 2014, Mansoor Samadi et al. showed the mean staining dots by AgNOR in specimens of normal mucosa, leukoplakia, and SCC increased, respectively. In 2017, Jajodia et al. evaluate the role of brush cytology in the screening of oral malignant suspicion lesions and showed that the sensitivity of oral SCC diagnosis by conventional cytology and liquid-based cytology was 75% and 85%, respectively, which improved on combining with the AgNOR count, with a cutoff of 6.5. The results of these studies were in line with those of our study.
Since the diagnosis of dysplastic changes and suspected malignant lesions is difficult, and sometimes, there is no strong evidence to proof malignancy, evaluation of cytomorphological changes, especially the use of AgNOR staining can be helpful.
The results of this study and other similar studies showed that salivary levels of copper increased in the people exposed to various levels of copper due to the occupational environment, and despite the absence of any apparent changes in the tissue, the mucosal cells exhibited cellular changes. These changes consisted of Class II and Class III of cytomorphology classes, which were confirmed by counting AgNOR-positive points and were higher than the control group. An interesting point in this study was that having longer working experience and more exposure period to copper, increased the amount of salivary copper, and also the changes in epithelial cells. The cytology changes and the number of colored points by AgNOR were higher in these workers than in the others with less work experience. This could indicate that the harmful effects of copper would increase due to the increasing duration and amount. Therefore, populations that are exposed to the particles and dust of this element require special attention.
| Conclusion|| |
According to the results of the study, it can be concluded that occupational exposure to copper increases the salivary levels of this element and causes some changes in mucosal cells. These changes consist of nuclear activity enhancement and an increase in the number of NOR in the nucleus. Since this increase is very high in salivary levels of copper and nuclear activity in oral SCC patients, exposure to copper should be considered an important risk factor for oral mucosal changes.
This study has been approved by the Research and Ethics Committee of Isfahan University of Medical Sciences and has been supported financially by grant No: 396089.
The authors also would like thanks from Mr. Nasr for his kind cooperation in staining the slides.
NT contributed in the conception of the work, conducting the study, definition of intellectual content, interpretation of data for the work, manuscript preparation, editing and review, approval of the final version of the manuscript, and agreed for all aspects of the work. AA contributed in the design of the study, definition of intellectual content, literature search, clinical and experimental, data acquisition, data analysis, statistical analysis, manuscript preparation, editing and review, approval of the final version of the manuscript, and agreed for all aspects of the work. NK contributed in the conducting the study, clinical and experimental and data acquisition, manuscript preparation, editing and review, approval of the final version of the manuscript, and agreed for all aspects of the work. AM contributed in the in the conducting the study, clinical, experimental and data acquisition, revising the draft, approval of the final version of the manuscript, and agreed for all aspects of the work.
Financial support and sponsorship
This study has been approved by the research and ethics committee of Isfahan University of medical sciences and has been supported financially by Grant No: 396089.
Conflicts of interest
The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or non-financial in this article.
| References|| |
Chan GG, Tai BC, Liang S, Lim DT, Soo KC. Squamous cell carcinoma of the head and neck (HNSCC) – Multi-modality treatment and impact on survival. Asian J Surg 2002;25:35-40.
Sudbø J, Bryne M, Johannessen AC, Kildal W, Danielsen HE, Reith A. Comparison of histological grading and large-scale genomic status (DNA ploidy) as prognostic tools in oral dysplasia. J Pathol 2001;194:303-10.
Neville BW, Damm DD, Allen CM, Chi AC. Oral and Maxillofacial Pathology. 4nd
ed. WB Saunders, Elsevier Health Sciences, Missouri; 2016. p. 382-5.
Rajendran R, Sellappa S. Serum copper and iron levels in oral squamous cell carcinoma patients: A South Indian study. Adv Appl Sci Res 2013;4:203-6.
Carton M, Barul C, Menvielle G, Cyr D, Sanchez M, Pilorget C, et al.
Occupational exposure to solvents and risk of head and neck cancer in women: A population-based case-control study in France. BMJ Open 2017;7:e012833.
Simmons SE, Pendergast DM, Graham E. The context and significance of copper artifacts in Postclassic and early historic Lamanai, Belize. JFA 2009;34:57-75.
Ayinampudi BK, Narsimhan M. Salivary copper and zinc levels in oral pre-malignant and malignant lesions. J Oral Maxillofac Pathol 2012;16:178-82. [Full text]
Armstrong CW, Moore LW Jr., Hackler RL, Miller GB Jr., Stroube RB. An outbreak of metal fume fever. Diagnostic use of urinary copper and zinc determinations. J Occup Med 1983;25:886-8.
Van Nieuw Amerongen A, Bolscher JG, Veerman EC. Salivary proteins: Protective and diagnostic value in cariology? Caries Res 2004;38:247-53.
Acha A, Ruesga MT, Rodríguez MJ, Martínez de Pancorbo MA, Aguirre JM. Applications of the oral scraped (exfoliative) cytology in oral cancer and precancer. Med Oral Patol Oral Cir Bucal 2005;10:95-102.
Montgomery PW. A study of exfoliative cytology of normal human oral mucosa. J Dent Res 1951;30:12-8.
Almeida JD, Cabral LA, Brandão AA. Exfoliative cytology as a diagnostic method in stomatology. J Dent Res1994;73:765.
Mohan BC, Angadi PV. Exfoliative cytological assessment of apparently normal buccal mucosa among quid chewers using Argyrophilic nucleolar organizer region counts and Papanicolaou staining. Acta Cytol 2013;57:164-70.
Hammer DS, Herberhold C, Pfeifer U. Argyrophilic nucleolar organizer region counts in squamous cell carcinomas of the head and neck after irradiation and chemotherapy. Eur Arch Otorhinolaryngol 1998;255:74-6.
Elangovan T, Mani NJ, Malathi N. Argyrophilic nucleolar organizer regions in inflammatory, premalignant, and malignant oral lesions: A quantitative and qualitative assessment. Indian J Dent Res 2008;19:141-6.
] [Full text]
Paiva RL, Sant'Ana Filho M, Bohrer PL, Lauxen Ida S, Rados PV. AgNOR quantification in cells of normal oral mucosa exposed to smoking and alcohol. A cytopathologic study. Anal Quant Cytol Histol 2004;26:175-80.
Warnakulasuriya KA, Johnson NW. Nucleolar organiser region (NOR) distribution as a diagnostic marker in oral keratosis, dysplasia and squamous cell carcinoma. J Oral Pathol Med 1993;22:77-81.
Salehinezhad J, Kalantari MR, Omidi AA, Zare R. Evaluation of AgNOR staining in exfoliative cytology of normal oral (buccal) mucosa: Effect of smoking. JMDS 2007;31:22-4.
Rao DS, Ali IM, Annigeri RG. Evaluation of diagnostic value of AgNOR and PAP in early detection of dysplastic changes in leukoplakia and lichen planus – A preliminary case-control study. J Oral Pathol Med 2017;46:56-60.
Crocker J, McGovern J. Nucleolar organiser regions in normal, cirrhotic, and carcinomatous livers. J Clin Pathol 1988;41:1044-8.
Mehrotra R, Yadav S. Oral squamous cell carcinoma: Etiology, pathogenesis and prognostic value of genomic alterations. Indian J Cancer 2006;43:60-6.
] [Full text]
Ramya R, Prakash S, Sudha S. Assessment of serum malondialdehyde in oral squamous cell carcinoma patients and its association with tobacco habits. JPBMS 2011;10:1-3.
Berman DW, Crump KS. A meta-analysis of asbestos-related cancer risk that addresses fiber size and mineral type. Crit Rev Toxicol 2008;38 Suppl 1:49-73.
Charbotel B, Fervers B, Droz JP. Occupational exposures in rare cancers: A critical review of the literature. Crit Rev Oncol Hematol 2014;90:99-134.
Al-Rawi NH, Talabani NG. Quantitative analysis of trace elements in saliva of oral cancer patients from Iraq. J Coll Dent 2005;17:32-5.
Gonzalez Segura I, Secchi D, Carrica A, Barello R, Arbelo D, Burgos A, et al.
Exfoliative cytology as a tool for monitoring pre-malignant and malignant lesions based on combined stains and morphometry techniques. J Oral Pathol Med 2015;44:178-84.
Verma R, Singh A, Badni M, Chandra A, Gupta S, Verma R. Evaluation of exfoliative cytology in the diagnosis of oral premalignant and malignant lesions: A cytomorphometric analysis. Dent Res J (Isfahan) 2015;12:83-8.
Mansoor Samadi F, Thattil Sebastian B, Singh A, Chandra S, Mohammad S, Singh A, et al.
Silver binding nucleolar organizer regions dots in oral leukoplakia with epithelial dysplasia and oral squamous cell carcinoma: An in vivo
study. ISRN Dent 2014;2014:479187.
Jajodia E, Raphael V, Shunyu NB, Ralte S, Pala S, Jitani AK. Brush cytology and AgNOR in the diagnosis of oral squamous cell carcinoma. Acta Cytol 2017;61:62-70.
Rajput DV, Tupkari JV. Early detection of oral cancer: PAP and AgNOR staining in brush biopsies. J Oral Maxillofac Pathol 2010;14:52-8.
] [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2]