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The Toluidine Blue Test inLesions of the Oral CavityE ug en e N . M ye rs , M .D .

T h e u se o f to lu id in e b lu e as an adju n ct in th e d iag n o sis o f ep id erm oidcan cer o f th e o ral ca vity h as b een d escribed by seve ral autho rs.1 -4 T h is inv iv o d em on stratio n o f o ra l cav ity cancers is b ased u po n the o b serv atio n th atth e to p ical ap p lication o f toluidine blue,an acido p h ilic m etach ro m atic n u clearstain , w ill stain an are a o f carcin o m ain situ o r inv asiv e carcin o m a, w hereasno rm al m uco sa w ill n o t stain .

T h is te st is q u ite usefu l in sev eralsitu atio n s. In th e larg e, far-adv an cedcan cer o f th e oral cav ity , th e a pp lic ation s are rath er lim ited , sin ce m ere inspec tio n o f th e le sio n m ay be su fficien tfo r c lin ical d iag no sis. Fig . 1 .) H istolog ic d iag n o sis is th en m ad e b y d irectb io p sy . H ow eve r, in le ss d istin ct a rea sw h ere d y spla sia o r h y p erk erato tic lesio ns are presen t, it is h elp ful to stainthe lesion to differen tiate it fro m atru e carcin om a. T he stain also m ay b eu se d to h elp d ifferen tiate a tra um atico r in flam m ato ry u lcer fro m a c ance r.S tain in g th e le sio n p rio r to ex cisio n ishe lp fu l in d eterm in in g th e m arg in s o fresection . In ad d itio n , stain in g cand em on strate a sm all seco n d prim a ry ora sate llite lesio n ad jac ent to a larg erlesion.

Dr. Myera 18 from the D epartm ent of Otolaryng olo gy H osp ita l o f th e U nive rsity o f P en nsylv an ia .Philadelphia Pennsylvania.

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T h e e arlier rep o rts o f S h edd , et al.an d S tro ng , et al. hav e v iv id ly de m onstrated th e u se o f th is sta in in o ral c ance r. 4 T h eir o b serv atio n s w ere lim itedto ep id erm oid carcin o m a, an d th e u su alb en ig n o ral lesio n s su ch as h y p erkerato sis, ly m pho id hy p erp lasia, lich en p lan u s, an d traum a tic u lceratio ns. W eha ve h ad th e o p p o rtun ity to stu d y7 0 p atien ts w ith lesion s in th e o ralcav ity w ith to lu id in e blue , a nd h avedem on strated p o sitiv e sta ining o f m elan o m a, fib ro sarcom a , an d lym p h o sarc om a in ad d itio n to epiderm oid c anc er.S tain in g o f th ese lesio ns has no t beenrepo rted in th e earlier series. T h e o bse rv ation th at m align an t le sio n s otherth an epide rm o id can cer ta ke th e to lu id in e b lu e stain p rom pted th is rep o rt.

Technique of StainingT he sa m e tech n iq u e o f stain in g w asu sed in 7 0 p atien ts w ith le sio n s o f th eo ral cav ity . T he pa tien t w as in structed

first to rin se th e m o uth w ith w ater, an dto sw allo w sev era l sip s of w ater. E x cesssaliv a w as asp irated w ith a su ctio n .A cetic acid o n e p ercent w as th en app lied w ith a co tto n ap p licator as am uco ly tic ag en t. If th ere w as a larged ep o sit o f fib rin or d eb ris in an ulcerth is w as also rem ov ed b y su ction . Asm all am ou nt o f to lu id in e b lu e on e p ercen t w as th en a pp lied, w ith a co tto nap plicato r, to th e entire lesio n andso m e o f th e surro u nd in g m u co sa. T h ep atien t th en rin se d h is m o u th w ith w ater to w ash a w ay the ex cess toluidineb lu e. C ases in w h ich th e to lu id in e b lu etest w as p o sitive w ere b io p sie d im m ed iately . In ad ditio n, m an y lesio n s w hichd id n o t tak e up th e stain w ere b io p siedto d ocu m en t th e nature of th e lesio n .T h o se n eg ative lesio ns w h ic h w ere no tb io p sied w ere k ep t u n d er clo se ob servation.

T h e efficacy o f this p ro ced ure w asd em on strate d in a series o f 7 0 p atients.T here w ere n o false po sitiv es. T h o selesio n s w hich d id no t stain w ere p ro ved

b y late r b io psy o r rep eat clin ica l e xamin atio n to b e ben ig n .

F orty -sev en p atients h ad ep id erm oidcarcin o m as. T w o p atie nts h ad m align ant m elano m a, on e fib ro sarco m a , an do ne ly m p h osarco m a. T h ese tu m o rs alld ye d v ery vividly . O n e patien t w ith arecu rren t ade no id cy stic carcin o m a o fth e b u ccal m u co sa w hich w a s n o t u lcerated d id n ot tak e the stain . It is imp o rtant to un d erstand th at o n ly th o selesio n s w hich h ave so m e u lceration ofth e m uco sa w ill tak e the sta in . T h o sew hic h are co mpletely m ucosal-co veredw ill no t.N ine patien ts w ere seen w ith u lceration s w h ich w ere eith er rad iatio n u lcers, in flam m ato ry ulcers, o r u lce rsfro m a trau m a in the bu ccal m u co sa.T h ese eith er staine d w eak ly , sp o tted lyo r n ot at all. T en o th er patien ts h adb en ig n lesion s w h ich did n o t stain , inc lu ding leuk o p lak ia, h y p erke ratosis,lich en plan us, a nd m edian rh o m bo idglossitis.

T he tw o p atients w ith m elan o m a inthe m u co sa o f th e h ard p alate w ere o fe xce ption al in terest. O n e w as a recu rren t m elano m a w hich h ad b een trea tedby electro d esiccatio n fiv e y ears prio r tostaining . A t th e tim e o f th e test th erew as a 5 m m . lesio n of rec ent orig in inth e an te rior p ortion o f th e h ard pa latew h ich w as m uco sa -co v ered ex cep t fo r asm all lin ear u lceratio n in th e centerof th e le sio n . T his w as fo u n d to stainp o sitive w ith toluidine b lu e. B io psyreve aled rec urren t m ela no m a, a nd th ep atien t w as a gain treated . T h e secon dp atien t w ith m elan o m a h ad a large u lcerated lesio n in th e ha rd palate w h ichw a s n ot p ig m ented an d to o k u p thestain v iv id ly . Fig . 2 .) T h e b io psyw as po sitiv e fo r m align an t m elan o m a.T h is p atien t p resen ted w ith tw o ad d itio na l pigm en ted m elano m as, on e o n th ean terio r an d o ne o n the lateral m ax illary alv eolus, an d bo th w ere p o sitiv efo r m elan o m a o n b iop sy . In ad ditio n tothe three p rim ary m u co u s m em b ran e

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on e p atien t h ad a th ird p rim ary ap pearafter tw o o th er o ral cav ity lesio ns h adbe en treated . T h e p atie nt w ith a m uco u s m em b rane m elan o m a de scrib edab ov e p resented w ith th ree d istin ct p rim ary lesio n s w idely sep ara ted in th em uc ou s m em bra ne .

T h is series is n ot b ro k en do w n in tolo catio n s in th e o ral cav ity altho u g hm o st o f th ese w ere in the to n g ue an dflo o r o f th e m o uth. Fig s. 3 an d 4 .)

m elan o m as, th e patien t p re sen ted w ithm etastases to o ne sid e of th e n eck, an dw ithin th ree m on th s d ev elo p ed m eta stases to the o th er sid e o f th e n eck.

O n e patien t h ad a fib ro sarco m a inv olving th e so ft and h ard p alate , th em ax illa, th e ph ary n x an d th e m an dib le .A larg e n ecro tic m ass w as p rese nt o nth e soft p alate. T h is d id no t stain , bu tadjacen t to th is w as a sm all u lc era tedarea in the h ard p alate n ear th e m ax illary tu b ercle w h ich did stain w ith toluidine b lu e. T his p ro v ed to be sp in d lecell fib ro sarcom a a nd a resection includ in g a p artial m an d ib ulecto m y, p artial m ax illecto my , an d p ha ry ng ecto myw as c arried ou t fo llo w e d b y rad iationtherapy.

T h is series inc lu ded a patien t w itha ly m p ho sarco m a of the to n sil w h ic hhad a sm all u lceration in th e c enter o fth e lesio n . T h is lesio n ha d th e ch aracteristics o f an ep id erm o id can cer. Itto o k u p th e to lu id in e b lu e stain , b u tb io p sy rev ealed ly m ph osarco m a. T hisw as treated w ith radiatio n therap y .

T w o pa tien ts h ad seco n d p rim aryepide rm oid carcin o m as in v ariou s p artso f the o ral cav ity at th e tim e o f th eirfirst exam ina tio n . In ad d ition , w e sawan o th er secon d p rim ary w hich ap p earedw ell a fter treatm ent o f th e first, an d

I g 4 S@ of large ulcerated squamouscancer in floor of m outh with two sm all satelliteareas posterior to the m ain tum or.H ow ev er, lesio ns w ere stain ed in areassuch as h ard an d so ft p alate , ton sil,alv eo lar rid g e, p osterio r p h ary ng ealw all, an d bu ccal m u cosa. F ig . 5 .) Inth e ad va nce d le sio n s it is d ifficu lt totell th e ex act p rim ary sites since tw o ,th ree or fo u r an ato m ical structures

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Fig. 2. D eeply ulcerated m alignant m elanom a.( Su rro un din g n orm a l m uc os a d oe s n ot s ta in .)

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can b e a vo id ed . T h e la ck o f false p o sitiv es o r n ega tiv es enh an ces its va lue a sa screen in g test.

T h e test itself is rem ark ab ly simple an d req u ires o nly clean sin g o f th eu lce r so th at th e stain w ill com e in contact w ith th e surface o f th e u lcer.E arlier stu dies h ave sh o w n tha t no rm alm u cou s m em b ran e d o es n o t stain;th erefo re, on e m u st n o t d ep end u p o nth is test fo r th o se tu m ors w hich sp readw ith ou t inv o lv em en t of o verly in g m uc ou s m e m br an e.T h e descrip tio n of p o sitiv e stain in gb y toluidine b lu e o f u lce rated tu m o rssu ch as m ela no m a, fib ro sarco m a, an dly m p ho sarco m a furth er ex ten d s th eu sefu ln ess of th is te st, w h ich h eretofore h as b een d escrib ed o nly in ep id erm o id can cer. T h e test is to b e u sed asan ad ju n ct an d as a screening test, an dis no t a su b stitute fo r b io p sy and c lo seo bserva tio n , w h ich are th e best w ay tod eal w ith lesion s of th e o ral cav ity .

References1. Niebel. H. H. and Chomet B .: In vivo stainingtest for delineation of oral intraepithelial neoplastic change: prelim inary report. J. Amer. Dent.Asen. 68: 801-806, 1964.2. Shedd D . P.; Hukill. P. B. and Bahn S.: Invivo staining properties of oral cancer. Amer. J.Surg. 110: 631.634, 1965.3. Shedd D. P. et al.: Further appraisal of invivo staining properties of oral cancer. Arch.Surg. Chicago 95: 16-22. 1967.4. Strong, M . S.; Vaughan, C. W .. and Incze. J. S.:Toluidine blue in the management of carcinomaof the oral cavity, Arch. Otolaryng. Chicago 87:527 531 1968.

Fig. 5. Sharply dem arcated squam ous cell carcinoma in soft palate stains vividly.m ay b e in v o lv ed. It is also in terestin gthat ben ig n an d m alig n an t lesio n s canco ex ist a t on e tim e. F ig ure 6 d em o nstrates an ep id erm o id can cer in th efloo r o f th e m o u th w h ich ha d b eentre ated w ith rad iation th erap y an d hadrecu rre d. A d jacen t to th is is a n area o fleu k o p lak ia w hich d oe s n o t tak e th estain. In th e crev ices o f th is lesio n , th estain d o es p u d dle an d sh ou ld n o t b em isin terp reted as being a p o sitiv estain.

DiscussionT h e use of to luidine b lu e as a screenin g test is a valua ble adjun ct to insp ection an d p alpatio n o f th e o ral

cav ity in th e se arc h fo r m align an tlesion s. It is of g reat u se in fo llo w -u pafter rad iatio n th erap y , o r after othe rtreatm en t fo r m uco u s m em b ran e lesio ns since u n nec essary b iop sies fo rp ostrad iatio n o r trau m atic u lceratio ns

Fig. 6. Recurrent cancer (left) stains. In leukoplakia (right) the toluidine blue puddles increvices. (This should not be m isinterpreted asa p os itiv e s ta in .)13 9