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How to catch a killer

Sept. 14, 2010
Oral cancer is growing at double-digit rates, despite declines in alcohol and tobacco use. Dr. Chris Farac explains how he has incorporated the Trimera® Identafi® 3000 into his routine exam on all patients age 18 and older to enhance the identification and visualization of oral mucosal abnormalities that may not be apparent or visible to the naked eye.
By Chris Farac, DMDI’d like to tell you about my personal experience with the Trimira® Identafi® 3000: a multispectral optical examination of oral lesions that I use in my dental office.What is the Trimira Identafi 3000?The Identafi 3000 is a battery-operated, hand-held, multispectral examination light used in conventional and specialized oral examinations. The Identafi 3000 enhances the identification and visualization of oral mucosal abnormalities that may not be apparent or visible to the naked eye, such as oral cancer or premalignant dysplasia. Why is this important to you and me?First, oral cancer is a deadly disease and if not caught early, its death rate is higher than that of cervical, testes, and thyroid cancers and Hodgkin's lymphoma. Oral cancer is growing at double-digit rates, despite declines in alcohol and tobacco use. This increase is due largely to the spread of HPV-16 and -18 via all forms of sex.1More than 40% of those diagnosed with oral cancer will die within five years.2 Second, if you do not die from it, imagine the pain and suffering that a patient must endure with all the surgeries required to repair facial disfigurements. While most clinicians will only see a few suspicious areas in their lifetime, in Washington State the statistical incidence of oral and pharyngeal cancer is slightly above the national average.1 Third, with all the scientific data that is currently being published linking sexual activity and HPV to oral cancer, I would not be taking care of you or your loved ones with the highest standard of dental care available today without the Identafi® 3000.How does this technology work?The Identafi 3000 excites oral tissue with multispectral lights for direct visualization of the natural tissue’s fluorescence and reflectance. Simply stated, where there is a loss of fluorescence and/or reflectance, there is a cause for concern. Trimira’s Identafi 3000 uses a 405 nm violet light. Studies show the best discrimination between neoplastic and non-neoplastic areas was obtained at 405 nm excitation; normal tissue could be discriminated from dysplasia and invasive cancer.3This device also helps us look at the vasculature through its reflectance technology. Where there is new growth (cancer or pre-cancer), there will be an increase in blood vessels feeding that new growth. Tumor-induced angiogenesis is the formation of new blood vessels from existing vasculature in response to chemical signals from a tumor. Angiogenesis marks the pivotal transition from benign solid tumor growth to vascular growth, a more progressive and potentially fatal stage of cancer beyond which cancer becomes extremely difficult to treat, existing therapies become ineffective, and survival rates decrease.4These same multispectral lights may also help the surgeon to identify the diseased tissue and assist in determining the appropriate margin for surgical excision. This means the surgeon has a better chance of getting all of the cancer the first time.What is the examination?The Identafi 3000 exam gives the clinician three specific lights to evaluate oral tissue, in addition to the tactile examination. There are no special rinses or dyes needed for the exam. We start with a white-light evaluation. While this view is similar to a regular dental chair lamp, working inside the mouth with the Identafi 3000 provides better light and access to the tonsils and base of the tongue where most squamous cell carcinomas are found. If I do not see anything under white light, I repeat the examination with the violet light to make sure we have not missed something.
Identafi — whiteThe 405 nm violet light causes normal tissue to autofluoresce. Normal tissue fluoresces brightly, while suspicious tissue does not. This is easily visible under the dimmed room light conditions in which the exam is performed. The point at which the loss of fluorescence is greatest is also the primary location for biopsy. This is important to you and the oral surgeons for biopsy to ensure a correct diagnosis. If I do not see anything with the violet light, the examination is over.
Identafi — violetIf I see something with either the white or violet light, I use the green-amber light. The green-amber light allows me to examine the vasculature at and near the tissue surface. The green-amber light also gives me a third look at the lesion’s morphology (structure and form). This third look helps me decide if I want to watch the area for a couple of weeks or send the patient directly to an oral surgeon.
Identafi — greenMy personal experienceI have incorporated the Identafi 3000 as part of my routine semiannual examination of all patients 18 years and older. I started this practice six months ago and will continue to do so. Patients are very receptive to this new tool in our arsenal that can potentially save lives.Five months into its use, we had a 64-year-old woman come into our office just before the New Year. I performed a standard oral exam as part of my standard of care, which consisted of looking and feeling using the Identafi 3000 to screen for cancer. During the exam, I did not see anything under white light. I switched to the violet light and noticed a spot on the patient’s tongue. The patient was promptly sent on to see an ear, nose, and throat specialist. She had that small spot removed by the surgeon. The biopsy results confirmed it was a squamous cell carcinoma. All of the cancer was removed with healthy borders remaining.Why now, why this paper, and why you should know about this!We did not see the cancerous lesion during the normal exam. We did not see it under white light. It was not until the violet light showed the lack of fluorescence that we saw the spot. The patient is fine now, and we are excited and confident that we provided her with the highest standard of dental care available today. What more could anyone ask for in their profession — knowing you have invested in a technology that truly provides an opportunity for exceptional patient outcomes.Chris Farac, DMD, is a general dentist in Kirkland, Wash.References1. National Cancer Institute / SEER; Oral Cavity and Pharynx. Age-Adjusted Invasive Cancer Incidence Rates and 95% Confidence Intervals by U.S. Census Region and Division, State and Metropolitan Area, and Race and Ethnicity, United States (Table National Cancer Institute3. Robyler D, Kurachi C, Stepanek V, Williams MD, El-Naggar AK, Lee JJ, Gillenwater AM, Richards-Kortum R. Objective detection and delineation of oral neoplasia using autofluorescence imaging. Cancer Prev Res (Phila Pa). Apr 28, 2009; 19401530 [My paper] 4. Bauer AL, Jackson TL, Jiang Y. A cell-based model exhibiting branching and anastomosis during tumor-induced angiogenesis. Biophys. J.. May 1, 2007; 92(9):3105-3121.