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Diagnostic accuracy of diffuse reflectance imaging for early detection of pre-malignant and malignant changes in the oral cavity: a feasibility study

Manju M Stephen1, Jayaraj L Jayanthi26, Nisha G Unni2, Philip E Kolady1, Valappil T Beena1, Panniyammakal Jeemon345 and Narayanan Subhash2*

Author Affiliations

1 Department of Oral and Maxillofacial Pathology, Government Dental College, Trivandrum, India

2 Biophotonics Laboratory, Centre for Earth Science Studies, Akkulam, Trivandrum 695 011, India

3 Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK

4 Centre for Chronic Disease Control, New Delhi, India

5 Public Health Foundation of India, New Delhi, India

6 Department of Surgical Oncology, Regional Cancer Centre, Trivandrum, India

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BMC Cancer 2013, 13:278  doi:10.1186/1471-2407-13-278

Published: 5 June 2013



Diffusely reflected light is influenced by cytologic and morphologic changes that take place during tissue transformation, such as, nuclear changes, extracellular matrix structure and composition as well as blood flow. Albeit with varying degree of sensitivity and specificity, the properties of diffusely reflected light in discriminating a variety of oral lesions have been demonstrated by our group in multiple studies using point monitoring systems. However, the point monitoring system could not identify the region with the most malignant potential in a single sitting.


In order to scan the entire lesion, we developed a multi-spectral imaging camera system that records diffuse reflectance (DR) images of the oral lesion at 545 and 575 nm with white light illumination. The diagnostic accuracy of the system for 2-dimensional DR imaging of pre-malignant and malignant changes in the oral cavity was evaluated through a clinical study in 55 patients and 23 healthy volunteers. The DR imaging data were compared with gold standard tissue biopsy and histopathology results.


In total 106- normal/clinically healthy sites, 20- pre-malignant and 29- malignant (SCC) sites were compared. While the median pixel value of the R545/R575 image ratio for normal/clinically healthy tissue was 0.87 (IQR = 0.82-0.94), they were 1.35 (IQR = 1.13-1.67) and 2.44 (IQR = 1.78-3.80) for pre-malignant and malignant lesions, respectively. Area under the ROC curve to differentiate malignant from normal/clinically healthy [AUC = 0.99 (95% CI: 0.99-1.00)], pre-malignant from normal/clinically healthy [AUC = 0.94 (95% CI: 0.86-1.00)], malignant from pre-malignant [AUC = 0.84 (95% CI: 0.73-0.95)] and pre-malignant and malignant from normal/clinically healthy [AUC = 0.97 (95% CI: 0.94-1.00)] lesions were desirable.


We find DR imaging to be very effective as a screening tool in locating the potentially malignant areas of oral lesions with relatively good diagnostic accuracy while comparing it to the gold standard histopathology.

Sensitivity; Specificity; Diffuse reflectance imaging; Oral squamous cell carcinoma