Salman Shafique* , Syed Mahmood Haider**, Zahid Ali***
- RMO, Department of Oral & Maxillofacial Surgery, Civil Hospital Karachi.
- Vice Principal & Head of Dental Department, Karachi Medical & Dental College, Head of Depatrment Oral & Maxillofacial Surgery, Abbasi Shaheed Hospital, Karachi.
- Assistant Professor, Department of Oral & Maxillofacial Surgery, Karachi Medical & Dental College, Karachi.
Correspondence: “Dr. Zahid Ali ” <email@example.com>,
How to CITE:
J Pak Dent Assoc 2010;19(3): 171 -176
The objective of our study was to identify the different histological patterns of Oral Squamous cell carcinoma (OSCC) in relevance to demographic variables and to evaluate histological patterns according to various clinical presentations at the joint department of Oral Surgery, Karachi Medical and Dental College and Abbasi Shaheed Hospital Karachi.
This descriptive study was conducted from December 2005 to November 2006 at Oral Surgery Department of Karachi Medical & Dental College and Abbasi Shaheed Hospital Karachi. A total of 60 cases presenting with OSCC were included in this study. Their demographic details, habit profile, clinical information of lesion were recorded on a proforma. All the patients underwent biopsy and their histological information was also noted on the same proforma.
This study included 60 patients of OSCC. Fifty eight percent of patients were from age group between 41-60 years. Approximately 63.3 % males and 36.7 % females were affected and male to female ratio was 1.7: 1. Approximately 48.3 % of lesions involved alveolus. Nearly 86.7 % of patients were indulged in habits of tobacco chewing. Clinical appearance of lesion showed that 66.7% of lesions were ulcerative type and histologically 48.3% were well-differentiated OSCC.
Majority of patients were indulged in habit of tobacco chewing. Ulcerative type was the dominant clinical presentation whereas histologically well-differentiated OSCC was the most common presentation. Infiltration was a consistent finding in all cases.
Oral Squamous cell carcinoma, ulcerative type, well- differentiated, oral cancer.
Worldwide Oral Squamous cell carcinoma is one of the most prevalent cancers and is one of the 10 most common causes of death.1 There is little variation in worldwide statistics, in Frenchmen, the incidence is up to 17.9 cases per 10,000 population and high rates are reported in India and Asian countries.2In Pakistan annual incidence rate of oral cancer was reported as 4.1 % per 100,000 males and Karachi cancer registry has shown oral cancer as the second most common malignancy and constitute about 9.8% of all the malignancies in Karachi south.3Oral cancer is disease of increasing age: approximately 95% of cases occur in people older than 40 yrs with an average age at diagnosis of approximately 60 years.4,5According to most of western literature tongue and floor of the mouth are the most common sites, followed by mandibular alveolus, buccal mucosa, hard palate and maxillary gingiva.6-9 In Indo-Pak region buccal mucosa is the most common site due to particular habits of smokeless tobacco.10Tobacco and alcohol are acknowledged risk factors for oral and oropharyngeal cancers.11 Epidemiological studies have shown that more than half the people with oral cancer are smokers.12,13 Use of smokeless tobacco products (chewing tobacco ,niswar,manpuri,gutka ) are also playing a significant role in oral cancer development.14Early squamous cell carcinoma may present as a white patch (leukoplakia), red patch (erythroplakia), or a mixed red and white lesion (erythroleukoplakia). With time,superficial ulceration of the mucosal surface may develop. Pain is not a reliable indicator as to whether a particular lesion may be malignant; larger, advanced carcinomas will often be painful, but many early oral cancers will be totally asymptomatic or may be associated with only minor discomfort. The purpose of this study was to identify the different histological patterns of OSCC in relevance to demographic variables and to evaluate histological patterns according to various clinical presentations.
This study was carried out in the joint department of Oral Surgery, Karachi Medical and Dental College and Abbassi Shaheed Hospital Karachi, during the period of one year from December 2005 to November 2006.
Every patient who consented (those patients who are clinically suspected and histologically proven cases of Oral Squamous cell carcinoma) for inclusion in this study had their demographic details and personal information, including their habits, recorded on a structured proforma. The patients from both sexes and all age group were included in this study. The mode of clinical presentation of their lesion were recorded in written and in the form of photographic records. Every patient underwent incisional biopsy by the principal investigator himself under local anesthesia or general anesthesia, as indicated. Their specimens were fixed in 10 % buffered formaline and specimens were subjected to histopathological examination.Histological details of lesion were recorded on same proforma. Data was analyzed by using SPSS version 10. Frequencies and percentages were computed for presentation of all categorical variables including age, gender, personal habits, clinical findings and histological types.
No interferential test was applicable for this descriptive study
General Overview:This study included 60 patients of OSCC. Fifty eight percent of patients were from age group between 41-60 years (Graph# 1). Approximately 63.3 % males and 36.7 % females were affected and male to female ratio was 1.7:1. Approximately 48.3 % of lesions involved alveolus. Nearly 86.7 % of patients indulged in habits of tobacco chewing. Clinical appearance of lesion showed that 66.7% of lesions were ulcerative type and histologically 48.3% were well-differentiated SCC.
Habits profile:A vast majority of patients were found indulged in habits of tobacco consumption either in form of cigarette or smoke less tobacco. Nearly 86.7% of patients had affirmative history of tobacco consumption and predominant mode of consumption was smoke less tobacco as pan with tobacco. Alcohol consumption was observed in only one patient.
Disease Profile: Clinically, ulcerative type of lesions was most common presentation. Forty out of 60 patients, which accounts for 66.7%, had ulcerative mode of clinical presentation of OSCC followed by exophitic and verrucous type that accounts for 30% and 3.3% respectively. (Table #1)
Histologically, well-differentiated OSCC was most prevalent type of presentation, constituting 48.3 % of all cases. Where as moderately differentiated were 35 % and poorly differentiated constitute as 16.7 % of all cases.
Histological detail according to various demographic variables: Demographically, among age group 1, which included patients from 21-40 years, equally presented as, well-differentiated and moderately differentiated OSCC was both 37.5 % (TABLE 2).
and moderately differentiated OSCC, was both 39.5%.However females presented well-differentiated OSCC as most common histological presentation (63.6%).(Table#3)
Among 29 cases of well-differentiated OSCC, 48.3 % were presented as Exophytic lesions and alveolus was most common site. Whereas moderately differentiated OSCC was presented as ulcerative type (85.7%) and buccal mucosa was the most common site, which exhibited moderately differentiated OSCC. Among poorly differentiated cases, ulcerative type of presentation was most common (90.0%) and tongue was the prevalent site for poorly differentiated OSCC (TABLE 4,5)
Squamous cell carcinoma of oral cavity represents one of the ten most frequent tumours, and shows a geographic incidence 3-6 % in western countries and 30% in eastern countries. Despite recent diagnostic and therapeutic improvements, prognosis of patients presenting this type of tumour remains very poor, probably on account of the different biological behaviour of these tumours, which shows a variable aggressiveness independently of clinico-pathological parameters of certain prognostic importance such as TNM staging and histological grading. 15
Regarding demographic variables, in our study most common age group was 41-60 yrs, which is easily comparable with local and regional studies. Western literature reports higher mean age, Ascani15 and colleagues reported 66.6 yrs as mean age group in their study where as Worall .16 in his audit of oral cancer reported 7th decade as most common age group which is in contrast to our observation and other regional studies.
Chen.17 in a retrospective study showed 52 yrs as mean age. Mehortra .18 from India reported 50-59 yrs age group as most common, which is very close to our findings. Isaac.19 has similar age group distribution in his study, 55.5 % of his study population was from age group 41- 60 yrs.
Gender wise distribution in our study revealed male preponderance, with males as 63.3 % and females as 36.7 %. Male to female ratio was 1.7:1. Similar findings have been reported by Wahid 20 in his study (male=64% and female= 36%) and another study from same setting by Zakai21 showed male preponderance (3: 1). Mehrotra18 has shown little higher male prevalence in comparison with Poorly females (76.57 % and 23.43% respectively). Oral cancer Differentiated is considered as disease of male, generally however (%) female are being affected in increased number in 10.0 comparison with previous studies due to increase in 0.0 incidence of tobacco habits among females in the form of 90.0 smoking as well as smokeless tobacco.22
Poorly As far as site of lesion is concerned, alveolus was the most common site in our study (48.3%), followed by buccal Differentiated (%) mucosa and other sites and these findings are very similar 5.6 to another study done in same setting. Haider23 reported 80.0 over 50 % of cases occurring on gingiva and alveolus as 10.3 the most common site effected by OSCC. Odokoya24 also 40.0 showed that alveolus was the most common site. Our 0.0 findings regarding site of lesion are in little contrast with other local researchers. Another study by Zakai25 indicated that buccal mucosa was the most common site. Approximately 46.6 % of his cases occurred on buccal mucosa.Wahid20 also reported buccal mucosa as most common site and so did Isaac26 Their figures for buccal mucosa as the most frequent site of lesion were indicated as 34.0 % and 43 % respectively. Ascani15, like other western researchers, reported tongue being the most common site involved. Nearly 42.2 % of his cases involved tongue. This difference is due to particular tobacco habits in our region. As smoking and consumption of alcohol is more frequent in western society as compared with our region where tobacco is used
in smokeless form more commonly and kept in the vestibular pouch as snuff, quid or other forms, giving rise to alveolar and buccal lesions predominantly.
Habit profile of study indicated that a vast majority of patients were found indulged in habits of tobacco and predominant mode of consumption was smokeless tobacco. Around 86.7 % patients had history of chewing pan with tobacco. Znoar 27 and colleagues, in their study determined smokeless tobacco as strongest risk factor for Oral Cancer because most of their patients were involved in habitual tobacco consumption. Similarly Ahmed28 documented a high percentage of tobacco chewing in the form of betel quid in their study. Another study at Hyderabad revealed 42 % of OSCC patients were involved in habit of tobacco consumption26 However Schmidt29 reported increased incidence of cigarette smoking associated with OSCC of floor of mouth and gingiva.
Clinical profile of lesion presented ulcerative type as most frequent appearance of OSCC. Approximately 66.7% cases had ulcerative appearance and only 3.3 % were presented with verrucous appearance. Najeeb30 in his study of Carcinoma of tongue documented 92 % of his cases as an ulcer. Zakai25 in his study at same setting reported that ulcerative presentation of OSCC is the most common one, however he further elaborated that 47% of his cases were presented with mixed ulcerative and exophytic appearance. In our study only 3.3 % of all cases were verrucous in appearance, which is in contrast to the findings of Zaidi31 He documented 15-17 % of his cases as verrucous presentation. Interestingly in our series all of verrucous cases were on lip. He further elaborated in his monograph that that incidence of verrucous carcinoma in southeastern population is significantly higher than other regions.
Histological distribution of OSCC in our study indicated a clear predominance of well-differentiated OSCC, which is in accordance with eastern studies and contrary to the western literature. Ascani15 documented majority of his cases as poorly differentiated OSCC as 35.9 % of his sample were found to be poorly differentiated OSCC. High prevalence of moderately differentiated OSCC were derived from Connecticut tumour registry32 Mehrotra18 reported majority of his cases as well differentiated OSCC and similar observations were recorded by Iype22 and he documented 52.6% of his cases as well differentiated OSCC. Findings of other local researchers are in consistence with that of ours, Isaac26and Khan33 documented 66 % and 67.5 % of their cases respectively as Well differentiated OSCC. However Najeeb30 in his analysis of SCC of tongue documented moderately differentiated as most frequent histological type.
Analysis of histological type according to demographic distribution indicated that well differentiated OSCC were seen in older age group (77.8%) and females commonly presented with this histological type of OSCC ( 63.6 %). These facts are in favor of findings of Odokoya24 and Ugboko32 They reported higher mean age associated with well-differentiated OSCC.( p= 0.05)
It was found in evaluation of clinical profile with histological type that majority of exophytic lesions were histologically well differentiated (48.3 %) whereas poorly differentiated lesion (90.0 %) exhibited ulcerative mode of clinical presentation.
Evaluation of histological types with clinical presentation indicated that well differentiated OSCC was most frequent type for alveolus (55.2%), Retromolar trigone (60 %) and lips (100 %). Where as lesions of buccal mucosa were presented as moderately differentiated type (61.1%) and tongue predominantly presented poorly differentiated type (80.0%) as most common histological picture. With little variation Ugboko32 recorded almost similar findings. He reported well-differentiated type as most common histological picture for all sites including tongue as well, which is in contrast to our observation. Najeeb30 documented in his case series of tongue cancers, moderately differentiated type as most frequent histological finding
The most common age group affected by disease was 41-60 yrs. Male preponderance was observed. Alveolus being the most common site involved. Majority of patients were indulged in habits of tobacco chewing. Ulcerative type was the dominant clinical presentation where as histologically well-differentiated OSCC was the most common presentation. Although well-differentiated type was most common histological presentation, poorly differentiated cases were more common in younger age group. Females presented with well-differentiated lesions more frequently than males. Poorly differentiated OSCC predominantly exhibited ulcerative clinical appearance and tongue was the most common site for such histological type. Whereas lesions of buccal mucosa were found moderately differentiated, predominantly, and well differentiated lesions for other sites. Infiltration was a consistent finding in all case.
It was a general observation during our study that most of the patients were from lower socio-economic background and at times it was difficult for them to bear expenses of their investigations including histopathological examination. Therefore it is recommended that all public sector tertiary care hospitals should be provided with specialties relevant to management of oral cancers.
An interesting finding observed during the study was the laterality of lesion, which was not recorded or noted in proforma. Most of the lesions were found on left side, although it does not bear any clinical significance but might be of statistical importance.
Further studies are recommended to compare different histological grading systems of OSCC and to co-relate them with disease outcome so that their influence on prognosis may be evaluated
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