|Year : 2017 | Volume
| Issue : 1 | Page : 14-20
Oral cancer profile among patients who underwent oral biopsy in a tertiary referral center in Central Kerala
Sandhya Kandath, Bobby John, G Shobitha
Department of Oral and Maxillofacial surgery, Government Dental College, Kottayam, Kerala, India
|Date of Web Publication||30-Jun-2017|
Kandath House, Kariyankode (PO), Anikode, Palakkad, Kerala
Source of Support: None, Conflict of Interest: None
Background: Oral cavity is one of the most common sites for cancer in our population due to a high prevalence of tobacco use in the country.
Aim: The aim of this study was to retrospectively assess the oral cancer profile among patients who underwent biopsy in a tertiary center in Central Kerala and thereby implement the preventive measures for controlling it.
Materials and Methods: This retrospective study was conducted by analyzing the histopathological records in the Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam, from June 2008 to May 2014.
Results: The study showed that among 1270 patients who underwent biopsy as a part of the diagnostic procedures during the study period, 570 (44.8%) patients were diagnosed as having dysplasia, premalignant and malignant lesions. Out of this, 361 patients were diagnosed with oral squamous cell carcinoma (SCC). There was an increased predilection of oral cancer among males and the predominant age group affected was between 61 and 70 years of age, followed by 30–40 years age group. Buccal mucosa was the most common site accounting for 42.6% of the total cases. The most prevalent histopathological pattern was moderately differentiated SCC. Statistically significant association was found between age group and histopathological grading, subsite, and histopathological grading with P< 0.005.
Conclusion: The increased prevalence and younger age group involvement of oral SCC in the study suggest that preventive measures should be implemented in our society at the earliest. The data found in the study can be used to make public awareness of the harmful effects of tobacco and alcohol.
Keywords: Histopathological grading; oral cancer; prevention; squamous cell carcinoma; tobacco
|How to cite this article:|
Kandath S, John B, Shobitha G. Oral cancer profile among patients who underwent oral biopsy in a tertiary referral center in Central Kerala. Indian J Multidiscip Dent 2017;7:14-20
|How to cite this URL:|
Kandath S, John B, Shobitha G. Oral cancer profile among patients who underwent oral biopsy in a tertiary referral center in Central Kerala. Indian J Multidiscip Dent [serial online] 2017 [cited 2017 Nov 17];7:14-20. Available from: http://www.ijmdent.com/text.asp?2017/7/1/14/209280
| Introduction|| |
Oral and pharyngeal cancer is considered as a major global burden of cancer, mainly due to the widespread use of tobacco and alcohol. Oral cancer is the 11th most common cancer globally. The World Health Organization estimates that 7.6 million people died of cancer in 2005 and 84 million people will die in the next 10 years if action is not taken. There is a wide geographical variation in the incidence of oral cancer, with approximately two-thirds of patients in the developing countries. More than 70% of all cancer deaths occur in low- and middle-income countries, where resources available for prevention, diagnosis, and treatment of cancer are limited or nonexistent. In Southeast Asia, cancer of the oral cavity ranks among the three most common types of cancer. Oral cancer is a major problem in India where the incidence is 12.6/100,000 population. This accounts for 50%–70% of all the cancers diagnosed. Ninety percent of oral cancers in South East Asia including India are linked to tobacco chewing and tobacco smoking.
Aims and objectives
The aim of the study was to assess the oral cancer profile and thereby implement the preventive measures for controlling oral cancer. The objectives of the study were to (1) study the pattern of distribution of oral squamous cell carcinoma (SCC) and other oral lesions among the patients who underwent biopsy, (2) to find the common age groups affected with oral cancer, (3) to assess the sex predilection of oral cancer, and (4) to evaluate the histopathological pattern among the cases.
| Materials and Methods|| |
Retrospective evaluation of the histopathological records of patients who underwent biopsy in the Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam, Kerala, India, for a 6-year period from June 2008 to May 2014 was done. The inclusion criteria were all histopathologically proven cases of oral SCC. Exclusion criteria involved cases with incomplete records, all the nonmalignant lesions, and other malignant lesions of nonepidermal origin.
| Results|| |
Among the total number of cases identified, a number of males and females were analyzed. The site-wise distribution was calculated to find the most predominant site of oral cancer among the cases attending the hospital. The histopathological staging was based on Broder's Grading System. All parameters of each patient according to the histopathologic reports were compiled in the datasheet, and statistical analysis was done using Microsoft Excel and Pearson's Chi-square test.
One thousand two hundred and seventy patients underwent biopsy as a part of the diagnostic procedures in the center during the study period. Five hundred and seventy (44.8%) patients were diagnosed as having various types of dysplasias, premalignant lesions, and malignancies [Table 1] and [Figure 1]. The remaining cases which included benign tumors, cystic lesions, polyps, fibro-osseous lesions, vascular lesions were not evaluated in the study.
Dysplasia of different types as mild, moderate, or severe was found in 112 patients. Fifty-five patients had premalignant lesions such as leukoplakia, erythroplakia, lichen planus, and oral submucous fibrosis. Sarcomas were less frequent in the maxillofacial region with only four cases of osteosarcoma and two cases of chondrosarcoma noted during the study period. SCC was the most common form of oral cancer with a total of 361 patients. Among this, there were 247 males (68.42%) and 114 females (31.57%) [Figure 2]. Mean age group affected was 63.41 years (ranging between 31 and 92 years). The maximum number of cases was between 61 and 70 years of age followed by the 30–40 age groups [Table 2] and [Figure 3].
|Figure 2: Sex distribution of patients with oral squamous cell carcinoma|
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The most common site of oral cancer was buccal mucosa (42.6%), followed by the lower alveolus (22.9%), tongue (18.5%), floor of mouth (6.9%), palate (4.4%), retromolar trigone (3%), lip (1.1%), and upper alveolus (0.2%) [Figure 4].
|Figure 4: Subsite distribution percentage of oral squamous cell carcinoma|
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Histopathological grading was based on Broder's grading system. Moderately differentiated SCC was the most prevalent histopathological pattern with 52% of the total cases [Table 3] and [Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10],[Figure 11],[Figure 12].
|Table 3: Histopathological grading with subsite distribution of number of patients|
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|Figure 5: Epithelial hyperplasia with severe dysplasia involving lower alveolus|
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|Figure 6: Moderately differentiated squamous cell carcinoma involving buccal mucosa|
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|Figure 7: Well-differentiated squamous cell carcinoma involving lower alveolus|
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|Figure 8: Moderately differentiated squamous cell carcinoma involving tongue|
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|Figure 9: Moderately differentiated squamous cell carcinoma involving upper alveolus|
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|Figure 10: Histopathological slide of well-differentiated squamous cell carcinoma|
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|Figure 11: Histopathological slide of moderately differentiated squamous cell carcinoma|
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|Figure 12: Histopathological slide of poorly differentiated squamous cell carcinoma|
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Association between the age group and histopathological grading was done using Pearson's Chi-square test. The predominant histopathological pattern found in the younger age group was well-differentiated SCC. As age advances, there was an increased prevalence of poorly differentiated SCC. The association between age group and histopathological differentiation was statistically significant with P< 0.05 [Table 4]. Association between the subsite distribution and histopathological grading was also done using Pearson's Chi-square test. Moderately differentiated SCC was predominant in all the subsites except lip, where all the lesions were well-differentiated and poorly differentiated SCC. There was a significant association between the histopathological grading and site of occurrence of SCC with P< 0.05 [Table 5].
| Discussion|| |
Oral cancer is the most common cancer in India accounting for 50%–70% of total cancer mortality. Approximately 85%–95% of all oral cancer is SCC. A high proportion of cases among males is due to high prevalence of tobacco consumption habits. Agrawal et al. have shown similar findings in their study. In 2004, Nair et al. reported that in India, oral cancer is the most common type of cancer in males and fifth most common cancer in females. The age group most commonly affected with oral SCC in the study is between 61 and 70 years (24%). The second highest age group involved was between 30 and 40 years (18%). Previously, it was considered that elderly age groups were commonly affected by oral cancer. This is supported by various studies suggesting an increased prevalence of oral cancer among elderly (>40 years of age). In our study along with this observation, a high incidence of oral cancer is noted among the younger age groups. This is a matter of serious concern. Literature suggests that oral cancers in young patients show a general trend of aggressive course and poor prognosis. Hence, preventive measures in oral cancer must be aimed mainly at this young age group, especially discouraging the use of tobacco. Verrucous carcinoma cases were comparatively less with only 14 cases reported during the study period. SCC is the most common type of oral cancer. Along with the results in this study, various literatures also strongly support this finding.
In the present study out of the total histopathological reports, 49% of patients were diagnosed as have malignant, premalignant lesions, and various forms of dysplasia. Among this, 392 cases (70%) were malignant, 55 (9.8%) premalignant, and 112 (20%) with dysplasia. Premalignant squamous lesions of the oral cavity are areas of altered epithelium that are at an increased risk for progression to SCC. Napier and Speight  reported that prevalence of premalignant oral lesions is approximately 1%–5%. Pai and Westra reported that the rates of oral squamous dysplasia and subsequent SCC are decreasing, closely paralleling the decrease in cigarette smoking. In the present study, a high percentage of premalignant and dysplastic lesions (29%) were observed. This proportion is much higher compared to other malignancies (7.5%) excluding SCC. Literatures  report that the major risk factors for oral squamous dysplasia and for SCC are tobacco smoking and alcohol consumption. Although these are independent risk factors, they are also synergistic with each other. The ultimate goal of accurately recognizing and grading dysplasia and premalignant lesions of the oral cavity is to understand the expected biologic behavior of the lesion and to guide management. Follow-up studies examining the progression of dysplasia to carcinoma have found that patients with any dysplasia progress to cancer in 5%–36% of cases.,, Hence, this group of patients should be recalled on regular basis, evaluated and surgical intervention planned at the earliest. Khandekar et al. reported that alveolus was the most common site of oral cancer, whereas Agrawal et al. reported that common site of oral cancer observed was tongue followed by buccal mucosa. In the present study, the most common site observed was buccal mucosa (41%) followed by lower alveolus (21%). This variation may be due to the difference in tobacco, pan chewing, and smoking habits among different populations. In our study group population in central Kerala, tobacco and pan chewing habit is more common. This accounts for the increased prevalence of cases in the buccal mucosa and lower alveolus.
Histological grading is an important diagnostic tool to predict the clinical and biological behavior of cancer. The biological activity of oral SCC is evaluated and categorized as highly, moderately, and poorly differentiated. Broder primarily developed this quantitative grading of cancer in 1920. Akhter reported that moderately differentiated variant of SCC is more common and that there is also an increased prevalence of lymph node metastasis in this group. In the present study also, there is an increased prevalence (44.5%) of moderately differentiated variant of SCC. The presence or absence of increased lymph node metastasis in this group should be taken into consideration during treatment planning and further follow-up. Well-differentiated SCC was predominantly found in the younger age group (35.9%). This suggests that a better prognosis can be obtained if this age group affected is recognized at an early stage. The study shows that the histopathological pattern among the older age group was poorly differentiated SCC. A significant association between the site distribution and histopathological grading was also obtained. This shows that moderately differentiated SCC was more common type with an exception of lip as noted in the study.
| Summary and Conclusion|| |
Oral cancer is considered a preventable condition to a large extent, due to the possibility of early detection and treatment. The early detection of cancer is of critical importance as survival rates markedly improve when the oral lesions are identified at early stage. The increased prevalence and younger age group involvement of oral SCC in the study suggest that preventive measures should be implemented in our society at the earliest. More number of cases involving buccal mucosa shows the tobacco and pan chewing habit of our population. Younger age groups affected in the study show an increased prevalence of well-differentiated variant of SCC. A significant association was also found between the site distribution and histopathological variant. Further studies and analysis may be necessary to generalize the findings of the study to a larger population. These data can also be used to make the public aware of the harmful effects of tobacco and alcohol and promote them to seek medical care at the earliest in the case of any suspicious lesions found in the oral cavity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN. 2008 v2.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 10. Lyon, France: International Agency for Research on Cancer; 2010. Available from: http://www.globocan.iarc.fr
Aguado T, Aitio A. Diagnosis and treatment. (Cancer control: Knowledge into action: WHO guide for effective programs; module 3) strengthening the prevention of oral cancer: The WHO Perspective. Community Dent Oral Epidemiol 2005;33:397-9.
Krolls SO, Hoffman S. Squamous cell carcinoma of the oral soft tissues: A statistical analysis of 14,253 cases by age, sex, and race of patients. J Am Dent Assoc 1976;92:571-4.
Agarwal KH, Rajderkar SS. Clinico-epidemiological profile of oral cancer: A hospital based study. IJCH 2012;24.
Khandekar SP, Bagdey PS, Tiwari RR. Oral cancer and some epidemiological factors: A hospital based study. Indian J Community Med 2006;31:157-9. [Full text]
Shah JP. Cancer of the Head and Neck. BC Decker Inc.; 2001. [A Selected Series of Cases Presenting to the Head and Neck Service of Memorial Sloan-Kettering Cancer Centre, New York].
Iype EM, Pandey M, Mathew A, Thomas G, Sebastian P, Nair MK. Oral cancer among patients under the age of 35 years. J Postgrad Med 2001;47:171-6.
] [Full text]
Akhter M, Hossain S, Rahman QB, Molla MR. A study on histological grading of oral squamous cell carcinoma and its co-relationship with regional metastasis. J Oral Maxillofac Pathol 2011;15:168-76. [Full text]
Gale N, Pilch BZ, Sidransky D. World Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck Tumors. Lyon, France: IARC Press; 2005. p. 177-9.
Napier SS, Speight PM. Natural history of potentially malignant oral lesions and conditions: An overview of the literature. J Oral Pathol Med 2008;37:1-10.
Pai SI, Westra WH. Molecular pathology of head and neck cancer: Implications for diagnosis, prognosis, and treatment. Annu Rev Pathol 2009;4:49-70.
Johnson N, Schmid S, Franceschi S. World Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck Tumors. Lyon, France: IARC Press; 2005. p. 168-75.
Silverman S Jr., Gorsky M, Lozada F. Oral leukoplakia and malignant transformation. A follow-up study of 257 patients. Cancer 1984;53:563-8.
Arduino PG, Surace A, Carbone M, Elia A, Massolini G, Gandolfo S, et al.
Outcome of oral dysplasia: A retrospective hospital-based study of 207 patients with a long follow-up. J Oral Pathol Med 2009;38:540-4.
Hogewind WF, van der Kwast WA, van der Waal I. Oral leukoplakia, with emphasis on malignant transformation. A follow-up study of 46 patients. J Craniomaxillofac Surg 1989;17:128-33.
Dissanayaka WL, Pitiyage G, Kumarasiri PV, Liyanage RL, Dias KD, Tilakaratne WM. Clinical and histopathologic parameters in survival of oral squamous cell carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:518-25.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]