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Histopathological study of malignant lesions of oral cavity.

INTRODUCTION

Oral cancer is a heterogeneous group of cancers arising from different parts of the oral cavity, with different predisposing factors, prevalence, and treatment outcomes. It is the sixth most common cancer reported globally with an annual incidence of over 300,000 cases, of which 62% arise in developing countries. [1] In comparison with the US population, where oral cavity cancer represents only about 3% of malignancies, it accounts for over 30% of all cancers in India, [2] posing a significant challenge to health services by both preventive and diagnostic means. Incidence of oral cancer in India continues to rise and accounts for 50-70% of total cancer mortality. [3]

Oral cancer is a major problem in the Indian subcontinent where it ranks among the top three types of cancer in the country. [4] Many epidemiological studies have provided strong evidence of an association between alcohol and tobacco, resulting in an increased risk of oral and pharyngeal tumors. [5] In addition to the above factors, India has a high prevalence of chewing tobacco mixtures. [6]

Because 5-year survival is directly related to stage at diagnosis, prevention, and early detection efforts have the potential not only for decreasing the incidence but also for improving the survival of those who develop this disease. Early diagnosis depends on an astute clinician or patient who may identify a suspicious lesion or symptom while it is still at an early stage and an accurate diagnosis by a pathologist.

The possibility of lymph node metastasis from oral squamous cell carcinomas (SCCs) can be predicted with the help of certain factors such as site, size, and histological differentiation of the tumor. [7]

MATERIALS AND METHODS

This study was carried out in Department of Pathology, at a tertiary care hospital in Ahmedabad for the duration of 18 months, from January 2014 to June 2015.

Inclusion Criteria

1. Lesions of oral cavity

2. Specimen which is adequate and representative of the lesion

3. Properly resected surgical specimens such as punch biopsies, incisional biopsies, wedge biopsies, surgical excision, and hemimandibulectomy are included in the study.

Exclusion Criteria

1. Inadequately preserved specimens with handling artifacts

2. Improper clinical record (history and examination)

3. Neoplasms arising from nasopharynx and oropharynx.

As a part of this study, 477 specimens of lesions of oral cavity were studied with main focus on histopathology of the lesion and keeping the following features in mind: Age, sex, and site of lesion.

RESULTS

Incidence of lesions of oral cavity in our institute during January 2014 to June 2015 was 4.01%, that is, 477 cases out of total specimens 11,886. Out of total 477 cases of lesions of oral cavity, 75 cases (15.72%) were of malignant lesions. Among the malignant lesions, SCC was the most common lesion having 68 cases (90.67%) followed by verrucous carcinoma having 4 cases (5.33%). There were 2 cases (2.67%) of non-Hodgkin's lymphoma and 1 case (1.33%) of adenoid cystic carcinoma (Table 1 and Figures 1-6).

Most common age group affected by malignant lesions of oral cavity is 31-40 years (28%) followed by 41-50 years (26.67%) (Table 2).

The present study showed that among the total of 75 cases of malignant lesions of oral cavity, 51 were males and 24 were females giving male:female ratio of 2.57:1 (Table 2).

The present study shows that most common sites affected by the malignant lesions were buccal mucosa (BM) (41.33%) followed by tongue (36.00%) (Table 3).

Most common age group affected by SCC was 31-40 years (27.94%) and 41-50 years (23.53%). Out of 68 cases of SCC, 50 (73.5%) were males and 18 (26.5%) were females with male:female ratio of 2.77 (Table 4).

Most common site affected by the SCC was BM (41.18%) followed by tongue (39.71%) in the present study (Table 5).

The present study shows moderately differentiated SCC (57.35%) as most common SCC (Table 6).

DISCUSSION

SCC was a most common variety of malignancy in all the studies, and thus its incidence is comparable in all the studies including present study.

Manjari et al. [8] studied malignant lesions of oral cavity, pharynx, larynx, and nasal cavity in Amritsar. In our study, malignant lesions only of oral cavity were considered. Manjari et al. [8] interpreted that the most common group was SCC (93.3%) followed by anaplastic carcinoma.

Durazzo et al. [9] found SCC to be the most common oral malignancy (90.3%).

In the study done by Wahid et al., [10] 94% cases were of SCC. There were also cases of adenocarcinoma, malignant melanoma, and acinar cell carcinoma.

In the study done by Bhattacharjee [11] (1993-2004), SCC (97.5%) was the most common histology.

In the study done by Ma"aita, [12] a retrospective study of 118 cases of oral cancers in Jordan, SCC (96%) was a most common malignant lesion. He also reported adenoid cystic carcinoma in 2.5% cases and mucoepidennoid and fibrosarcoma in 0.75% each.

In a study done by Hassawi, [13] SCC was the most common malignant lesion consisting of 58.9% cases. The study also had 10.2% cases of adenoid cystic carcinoma and 7.8% cases of non-Hodgkin's lymphoma.

In a study done by Bal, [14] SCC was most common malignancy consisting of 95.1% of cases.

In the present study, incidence of verrucous carcinoma is 5.1% which is also comparable with the study done by Hassawi (Table 7). [13]

Most common age group affected by malignant lesions in a study done by Shanna [15] and in a study done by Saxena and Agarwal [16] were also 31-50 years which is in accordance with the present study as shown in Table 8. Haribhakti and Mehta [17] and Manjari et al. [8] showed 41-60 years as most common age group being involved which is a decade later than the present study (Table 8).

In our study, male:female ratio is 2.57:1 which is comparable with other studies as shown in Table 9. All the study showed male predominance (Table 9).

In our study, most common sites affected by the malignant lesions were BM (41.33%) followed by tongue (36.00%) (Table 3). Most common site involved by malignant lesions of oral cavity in other studies such as study done by Sharma, [15] Saxena and Agarwal, [16] Paymaster, [18] Haribhakti and Mehta, [17] and Mehta et al. [19] was BM constituting 48.4%, 56.8%, 45.64%, 49.5%, and 50%, respectively, which is in accordance with the present study. Mehrotra et al. [20] showed tongue as the most common site of oral malignant lesions consisting of 42.57% of cases and BM as the second most common site of oral malignant lesion consisting of 19.14%. A study done by Mehrotra et al. in 2008 [21] showed tongue (37.8%) as the most common site being involved by oral malignant lesion followed by BM (33.7%) which shows an increase in the incidence of malignant oral lesions at BM. A study done by Bhat [22] also showed tongue as the most common site followed by BM consisting of 35.5% and 27.2%, respectively (Table 10).

Table 11 compares the incidence of SCC among various studies of oral malignancies. It can be seen that SCC is predominant over all other types of oral malignancies. This finding was replicated in all the studies with the incidences more than 90% in all studies irrespective of year or geographic location of the study except study done by Hassawi [13] which showed 58.9% incidence of SCC.

In comparison with other studies, the present study shows moderately differentiated SCC (57.35%) as most common SCC while study done by Ma'aita [12] showed 44% cases of well-differentiated SCC and 42% cases of moderately differentiated SCC and study done by Patel and Pandya [23] show well-differentiated SCC (60.12%) as the most common SCC which can be explained by objective variation (Table 12).

CONCLUSION

Our study has revealed that SCC was the most common malignant lesions seen in oral cavity and moderately differentiated SCC was the predominant tumor type. Most common age group affected by malignant lesions was 31-40 years (28%) followed by 41-50 years (26.67%) with male:female ratio of 2.57:1 and most common site involved was BM followed by tongue (39.71%). The possibility of lymph node metastasis from oral SCCs can be predicted with the help of certain factors such as site, size, and histological differentiation of the tumor; hence, the study of site and differentiation is important.

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[5.] Madani AH, Jahromi AS, Dikshit M, Bhaduri D. Risk assessment of tobacco types and oral cancer. Am J Pharmacol Toxicol. 2010;5:9-13.

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[8.] Manjari M, Popli R, Paul S, Gupta VP, Kaholon SK. Prevalence of oral cavity, pharynx, larynx, nasal cavity malignancies in Amritsar, Punjab. Indian J Otolaryngol Head Neck Surg. 1996;48(3):191-5.

[9.] Durazzo MD, de Araujo CE, Brandao Neto Jde S, Potenza Ade S, Costa P, Takeda F, et al. Clinical and epidemiological features of oral cancer in a medical school teaching hospital from 1994 to 2002: Increasing incidence in women, predominance of advanced local disease, and low incidence of neck metastases. Clinics (Sao Paulo). 2005;60(4):293-8.

[10.] Wahid A, Ahmad S, Sajjad M. Pattern of carcinoma of oral cavity reporting at dental department of Ayub medical college. J Ayub Med Coll Abbottabad. 2005;17(1):65-6.

[11.] Bhattacharjee A, Chakraborty A, Purkaystha P. Prevalence of head and neck cancers in the north east-An institutional study. Indian J Otolaiyngol Head Neck Surg. 2006;58(1): 15-9.

[12.] Ma'aita JK. Oral cancer in Jordan: Aretrospective study of 118 patients. Croat Med J. 2000;41(1):64-9.

[13.] Hassawi BA. Tumors and tumor like lesions of the oral cavity. A study of 303 cases. Tikrit Med J. 2010;16(1): 177-83.

[14.] Bal MS. Aclinico-pathological study of 200 cases of oral cavity lesions. Res J Pharm Biol Chem Sci. 2014;5(6): 1035-40.

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[16.] Saxena ON, Agarwal GR. Oral cancer. A statistical study of 963 cases. J Indian Med Assoc. 1965;44:119-22.

[17.] Haribhakti VV, Mehta AR. Composite resections for oral cancers--Experience with 97 consecutive cases. Indian J Cancer. 1990;27:195-202.

[18.] Paymaster JC. The problem of cancer in India. J Indian Med Assoc. 1971;57(2):37-44.

[19.] Mehta MV, Dave KK, Gonsai RN, Goswami HM, Patel PS, Kadam TB. Histopathological study of oral cavity lesions: A study on 100 cases. Int J Cur Res Rev. 2013;5(10): 110-6.

[20.] Mehrotra R, Singh M, Kumar D, Pandey AN, Gupta RK, Sinha US. Age specific incidence rate and pathological spectrum of oral cancer in Allahabad. Indian J Med Sci. 2003;57(9):400-4.

[21.] Mehrotra R, Pandya S, Chaudhary AK, Kumar M, Singh M. Prevalence of oral pre-malignant and malignant lesions at a tertiary level hospital in Allahabad, India. Asian Pac J Cancer Prev. 2008;9(2):263-5.

[22.] Bhat SP. Oral and oropharyngeal malignancy: A clinicopathological study. IJRCI. 2015;1(1):OA1.

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Pooja Y Shah, Ravi G Patel, Shridhan G Prajapati

Department of Pathology, B. J. Medical College, Ahmedabad, Gujarat, India

Correspondence to: Pooja Y Shah, E-mail: shahpooja9789@gmail.com

Received: August 12, 2016; Accepted: September 18, 2016

DOI: 10.5455/ijmsph.2017.0848018092016

Source of Support: Nil, Conflict of Interest: None declared.

Caption: Figure 1: Well-differentiated squamous cell carcinoma (x4)

Caption: Figure 2: Moderately differentiated squamous cell carcinoma (x20)

Caption: Figure 3: Poorly differentiated squamous cell carcinoma (x 10)

Caption: Figure 4: Papillary squamous cell carcinoma (x20)

Caption: Figure 5: Adenoid cystic carcinoma (x 10)

Caption: Figure 6: High-grade non-Hodgkin's lymphoma (x40)
Table 1 : Histopathological spectrum of malignant lesions
of oral cavity in the present study

Malignant lesions          Number of cases (%)

SCC                            68 (90.67)
Verrucous carcinoma             4 (5.33)
Adenoid cystic carcinoma        1 (1.33)
Non-Hodgkin's lymphoma          2 (2.67)
Total                          75 (100.00)

SCC: Squamous cell carcinoma

Table 2: Age and sex incidence of oral malignant lesions
in our study

Age in years   Male   Female    Total (%)

0-10            0       0       0 (0.00)
11-20           0       0       0 (0.00)
21-30           9       2      11 (14.67)
31-40           18      3      21 (28.00)
41-50           11      9      20 (26.67)
51-60           8       4      12 (16.00)
61-70           6       2       8 (10.67)
71-80           2       1       3 (4.00)
>80             0       0       0 (0.00)
Total           54      21     75 (100.00)

Table 3: Site-wise distribution of malignant lesions of oral
cavity in the present study

Site                      Malignant lesions

                          Number of case (%)

Lips                           3 (4.00)
FOM                            0 (0.00)
Tongue                        27 (36.00)
BM                            31 (41.33)
Gingiva (alveolar ridge)       6 (8.00)
RMT                            3 (4.00)
Hard palate                    2 (2.67)
Tonsillar region               3 (4.00)
Soft palate                    0 (0.00)
Mandible                       0 (0.00)
Maxilla                        0 (0.00)
Others                         0 (0.00)
Total                        75 (100.00)

BM: Buccal mucosa, RMT: Retromolar trigone, FOM: Floor of mouth

Table 4: Age- and sex-wise distribution of SCC in present
study

Age in years     Male       Female     Total (%)

0-10               0           0        0 (0.00)
11-20              0           0        0 (0.00)
21-30              9           2       11 (16.18)
31-40             16           3       19 (27.94)
41-50             10           6       16 (23.53)
51-60              8           4       12 (17.65)
61-70              6           2       8 (11.76)
71-80              1           1        2 (2.94)
>80                0           0        0 (0.00)
Total (%)      50 (73.5)   18 (26.5)    68 (100)

SCC: Squamous cell carcinoma

Table 5: Site-wise distribution of SCC in the present study

Site                       Number of cases (%)

Lips                            2 (2.94)
FOM                             0 (0.00)
Tongue                         27 (39.71)
BM                             28 (41.18)
Gingiva (alveolar ridge)        5 (7.35)
RMT                             3 (4.41)
Hard palate                     2 (2.94)
Tonsillar region                1 (1.47)
Soft palate                     0 (0.00)
Mandible                        0 (0.00)
Maxilla                         0 (0.00)
Others                          0 (0.00)
Total                          68 (100.00)

SCC: Squamous cell carcinoma, BM: Buccal mucosa,
RMT: Retromolar trigone, FOM: Floor of mouth

Table 6: Histological grading of SCC in the present study

Histopathological grading of SCC   Number of cases (%]

Well differentiated SCC                21 (30.88)
Moderately differentiated SCC          39 (57.35)
Poorly differentiated SCC               6 (8.82)
Papillary SCC                           1 (1.47)
SCC with adenoid pattern                1 (1.47)
Total                                  68 (100.00)

SCC: Squamous cell carcinoma

Table 7: Comparison of histopathological spectrum of malignant
lesions of oral cavity

Histological            Manjari     Ma'aita [12]    Durazzo
typing                 et al. [8]       (%)        et al. [9]
                          (%)                          (%)

SCC                      93.35           96           90.3
Adenocarcinoma            0.38           --
Adenoid cystic            1.71          2.5             4
carcinoma
Mucoepidermoid            0.19          0.75
Anaplastic carcinoma      3.23           --            4.6
Malignant melanoma        0.19           --            --
Non Hodgkin lymphoma      0.38           --            --
Lymphoepithelioma         0.57           --            --
Verrucous                  --            --            1.1
carcinoma
Acinar cell                --            --            --
carcinoma
Embryonal RMS              --            --            --
Fibro sarcoma              --           0.75           --
Kaposi sarcoma
Osteosarcoma
Others

Histological              Wahid       Bhattacharjee [11]
typing                  et al. [10]          (%)
                           (%)

SCC                         94               97.5
Adenocarcinoma              2                0.31
Adenoid cystic              --               0.93
carcinoma
Mucoepidermoid              --               0.31
Anaplastic carcinoma        --                --
Malignant melanoma          2                 --
Non Hodgkin lymphoma        --                --
Lymphoepithelioma           --                --
Verrucous                   --               0.62
carcinoma
Acinar cell                 --                --
carcinoma
Embryonal RMS               --                --
Fibro sarcoma               --                --
Kaposi sarcoma
Osteosarcoma
Others

Histological           Hassawi [13]   Bal [14]   Present
typing                     (%)          (%)       study
                                                   (%)

SCC                        58.9         95.1      90.67
Adenocarcinoma              --           --        --
Adenoid cystic             10.2         1.0       1.33
carcinoma
Mucoepidermoid             5.1           --        --
Anaplastic carcinoma        --           --        --
Malignant melanoma          --           --        --
Non Hodgkin lymphoma       7.8           --       2.67
Lymphoepithelioma           --           --        --
Verrucous                  5.1          1.9       5.33
carcinoma
Acinar cell                 --          1.0        --
carcinoma
Embryonal RMS              5.1           --        --
Fibro sarcoma                            --        --
Kaposi sarcoma             2.5           --
Osteosarcoma               5.1           --
Others                                   1

RMS: Rhabdomyosarcoma, SCC: Squamous cell carcinoma

Table 8: Comparison of age incidence of oral malignant lesions
of the present study with other studies

Age        Present study       Sharma          Saxena and
in years        (%)        et al. [15] (%)   Agarwal [16] (%)

0-10           0.00              --                 --
11-20          0.00             1.60                --
21-30          14.67                               7.26
31-40          28.00            32.80             26.06
41-50          26.67            33.70             34.78
51-60          16.00            26.20             21.39
61-70          10.67            5.70               7.99
71-80          4.00                                2.28
>80            0.00             0.00               0.20
Total         100.00           100.00             100.00

Age        Haribhakti and      Manjari
in years   Mehta [17] (%)   et al. [8] (%)

0-10             --               --
11-20           2.10             2.09
21-30           3.10             6.46
31-40          21.60            16.15
41-50          33.00            31.93
51-60          31.00            25.85
61-70           8.20            13.34
71-80           1.00             3.16
>80             0.00             0.57
Total          100.00           100.00

Table 9: Comparison of sex distribution of oral malignant
tumors

Name of the study          Male:female ratio

Sharma et al. [15]              3.95:1
Haribhakti and Mehta [17]       1.84:1
Manjari et al. [8]              2.18:1
Mehrotra et al. [20]            3.27:1
Bhattacharjee [11]              2.14:1
Present study                   2.57:1

Table 10: Comparison of site-wise distribution of malignant lesions
of oral cavity of the present study with other studies

Site              Sharma       Saxena and    Paymaster   Haribhakti
                et al. [15]   Agarwal [16]     [18]         and
                    (%)           (%)           (%)        Mehta
                                                          [17] (%)

Cheek/BM           48.4           56.8         45.64        49.5
Tongue             36.9           28.9          27          8.3
Soft palate         2.4           4.3          4.36          --
RMT                 --             --           --          9.3
Lip                 5.7           3.3          2.96         6.2
Gingiva/            5.7           6.7          15.80        20.6
alveolar ridge
FOM                 0.9            --          4.24         3.1
Maxilla             --             --           --           3
Others              --             --           --           --

Site             Mehrotra        Mehta      Bhat [22]    Present
                et al. [20]   et al. [19]      (%)      study (%)
                    (%)           (%)

Cheek/BM           19.14          50          27.2        41.33
Tongue             42.57         33.3         35.5        36.00
Soft palate        6.27           --           3.9         --
RMT                 --            --           1.4          4
Lip                5.94           --           5.4          4
Gingiva/           7.92          4.16          4.4          8
alveolar ridge
FOM                0.33           --           3.4         --
Maxilla             --            --           --          --
Others             7.59          12.5         21.5          6

BM: Buccal mucosa, RMT: Retromolar trigone, FOM: Floor of mouth

Table 11: Incidence of SCC in various studies

Author                      Incidence of SCC (%)

Manjari et al. [8]                 93.35
Ma'aita [12]                         96
Durazzo et al. [9]                  90.3
Wahid et al. [10]                    94
Bhattacharjee et al. [11]           97.5
Hassawi [13]                        58.9
Bal [14]                            95.1
Present study                      90.67

SCC: Squamous cell carcinoma

Table 12: Comparison of histological grading of SCC

Histological grading       Ma'aita [12]    Patel and    Present
of invasive squamous           (%)        Pandya [23]    study
cell carcinoma                                (%)         (%)

Well differentiated             44           60.12       30.88
Moderately differentiated       42           38.70       57.35
Poorly differentiated           14           1.18        8.82

SCC: Squamous cell carcinoma
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Title Annotation:Research Article
Author:Shah, Pooja Y.; Patel, Ravi G.; Prajapati, Shridhan G.
Publication:International Journal of Medical Science and Public Health
Article Type:Report
Geographic Code:9INDI
Date:Mar 1, 2017
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