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01.12.2012 | Research | Ausgabe 1/2012 Open Access

World Journal of Surgical Oncology 1/2012

A comparative analysis of toluidine blue with frozen section in oral squamous cell carcinoma

World Journal of Surgical Oncology > Ausgabe 1/2012
Montasir Junaid, Moaz M Choudhary, Zain A Sobani, Ghulam Murtaza, Sadaf Qadeer, Naeem S Ali, Mumtaz J Khan, Anwar Suhail
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1477-7819-10-57) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

MJ came up with the idea, wrote the protocol and obtained the ethical committee approval, MC, ZA, MJ did most of the literature review and were mainly involved in the preparing of the manuscript, MK and AS were the primary surgeons and supervised the manuscript writing, SQ and NA were responsible for prepration of dye, obtaining informed consent, application of the dye intra-operatively, observing the results and maintaining the log, GM provided with the necessary statistical input and evaluation of data and results. All authors read and approved the final manuscript.



Surgical excision of the primary tumor with safe margins remains the mainstay of treatment for oral cavity squamous cell carcinoma (OSCC). The standard of care for assessment of intraoperative margins is frozen section histopathology. Unfortunately the facility is not available at most centers in limited resource countries. Toluidine blue, a metachromatic dye, has been well described in clinical identification of malignant and premalignant lesion in the oral cavity. Considering this we decided to explore intraoperative use of toluidine blue staining, in comparison with frozen sections, for the assessment of tumor-free margins.


After obtaining clearance from the in-house ethical review committee, a prospective study was conducted at Aga Khan University Hospital, Karachi, from August 15, 2009 to March 14, 2010. A sample of 56 consenting patients with biopsy-proven OSCC were included in the study, giving us 280 tumor margins. Margins were analyzed using toluidine blue staining and frozen section histopathology. A receiver operator curve (ROC) was then applied to compare assessment of margin status by toluidine blue and frozen section.


Of the 280 examined margins 11 stained positive with toluidine blue, three were positive on frozen section biopsy, and three were positive on final histopathology. Toluidine blue staining had sensitivity and specificity of 100% and 97%, respectively. The diagnostic accuracy of toluidine blue was found to be 97.1% with a positive predictive value (PPV) of 27.2% and a negative predictive value (NPV) of 100%.


Toluidine blue can be used as an effective screening modality for the assessment of intraoperative margins in resource limited environments and reducing the number of frozen section biopsies performed. Further by providing real-time clinical information within minutes it can reduce indirect costs such as operating room time. It may also be used as an ad hoc for frozen section biopsies where frozen section facilities are available.
Authors’ original file for figure 1
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