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Etiology of Oral and Oral Pharyngeal Cancer - Tobacco, Pan Masala, Gutka (Gutkha) and Alcohol
 
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Clinicopathological Spectrum of Malignancies of Oral Cavity and Oropharynx- Our Experience in a Referral Hospital

Authors: Shubha P Bhat*, Ramesh Naik C N**, G K Swetadri**, Hilda D’souza**, Jayaprakash C S**, Vadisha Bhat***
* Assistant Professor of Pathology, ** Professor of Pathology, ***Assistant Professor of ENT

Institution: Department of Pathology K S Hegde Medical Academy Deralakatte, Mangalore, India (Bhat SP and Bhat V)
and Father Muller Medical College, Kankanady, Mangalore, India  (Ramesh NCN, Swetadri GK, D’Souza H, Jayaprakash CS)

Corresponding Author: 

Shubha P Bhat MD(Pathology)
Assistant professor Department of Pathology
K S Hegde Medical Academy
Deralakatte Mangalore-575018, Karnataka
Email: bhatshubha_257@rediffmail.com

Abstract:

Cancer of the oral cavity is one of the common malignancies in developing countries. It is common in males compared to females and is usually seen after middle age. The incidence of oral cancer is increasing, however, in the younger generation in recent years. Etiology of oral and oropharyngeal malignancy is multifactorial, but the commonest etiological factors found are tobacco and alcohol consumption. In this study, we have studied the distribution of oral cavity and oropharyngeal malignancies in relation to age, sex, site, personal habits, histological type and differentiation. Out of the 100 patients studied, the majority were males. The average age was 60 years. Tobacco consumption in the form of smoking and smokeless tobacco was the common etiological factor noticed. Anatomically, more anterior parts in the oral cavity are the common sites involved. Squamous cell carcinoma was the most common histological type, with the majority of them being well differentiated.

 
Introduction:

Oral cancer is one of the most common cancers in developing countries. Oral cancer is the commonest cancer in India accounting for 50-70% of total cancer mortality. Though it is more common in males, the rate is increasing in females also. The high proportion of cases among males may be due to the high prevalence of tobacco consumption habits. Over the years, the incidence of oral cancers in the population has increased manifold especially among the younger generation, possibly related to the rising trend of pan and gutkha chewing, smoking and alcohol consumption.  Smokeless tobacco use has also been implicated for the etiology of oral pre-cancerous and cancerous lesions.  In the South Asian region, over one-third of the tobacco consumed is smokeless.  Traditional forms like betel quid, tobacco with lime, and tobacco tooth powder are commonly used and the use of new products is increasing, not only among men but also among children, teenagers and women.  The purpose of this study is to determine the distribution of oral cavity and oropharyngeal malignancies in relation to age, sex, site, personal habits, histopathological type and differentiation.

Methods:

This study was conducted in the Department of Pathology, Father Muller Medical College Hospital, Kankanady, Mangalore. A total of 100 patients were studied. Patients having a complaint of growth in the oral cavity and oropharynx were selected using purposive sampling technique. A detailed history was recorded in a proforma, regarding age, sex, presenting complaints, habits as type of chewing (see Table Below), smoking and consumption of alcohol.  A thorough examination of the oral cavity and oropharynx was done and the site of growth was noted. Biopsy was taken from the growth and was transferred to a bottle containing 10% neutral formalin, processed, embedded in paraffin and 3-4 µ thick sections were made. They were stained with Hematoxylin and Eosin stain. Histopathological diagnosis regarding type and differentiation was made.

Table 1:  Type of Chewing Mixtures -  From Chhaya et al.

Name of Mixtures Components
Betel Quid Areca Nut, Tobacco, Fresh Betel Leaf, Slaked Lime and Catechu
Pan Masala Areca Nut, Slaked Lime, Catechu and Condiments.
Gutka (Gutkha) Pan Masala and Tobacco
Mainpuri Areca Nut, Tobacco, Slaked Lime, Camphor and Cloves
Mawa Areca Nut, Tobacco and Slaked Lime
Khaini Tobacco, Slaked Lime

Results

We studied 100 patients having the complaint of growth in the oral cavity and oropharynx.  The majority (77%) of the patients were males. Only 23% were females. The mean age was 60.  The maximum number of patients were in the age range of 50-59 (30%), followed by 60-69 (24%) and 70-79 (21%).  The youngest patient in our study was 30 years old. Only 4% of the patients were less than 40 years of age.  Among the 100 patients with oral and oropharyngeal cancer, 58% gave a history of smoking while 52% were consuming smokeless tobacco in the form of gutkha or consuming pan.  Alcohol consumption was found in 37% of our patients.  44% were using alcohol as well as tobacco, either smoking or chewing.

Among the 23 female patients, 15 (65.2%) were chewing pan, which is the only habit found in female patients in our study. The other 8 (34.8%) females were not having any habit.  The most common symptom in our study was an oral lesion as 71% of the patients presented with the complaint of an oral lesion-like growth, nodule or an ulcer.  Other complaints were oral pain, dysphagia, neck swelling, oral bleeding and speech difficulty.

In our study, the buccal mucosa was the most common site involved (22%), followed by oral tongue (21%) and base of tongue (10%). Different sites and their frequency of involvement is shown in Table 2.


Table 2: Location of Primary Tumor

Location Number (Percentage)  
Lip* 7 (7%)  
Buccal mucosa (cheek) 22 (22%)  
Oral Tongue* 21 (21%)  
Floor of Mouth 6 (6%)  
Alveolus 6 (6%)  
Hard Palate 6 (6%)  
Soft Palate 5 (5%)  
Base of Tongue 10 (10%)  
Tonsil 9 (9%)
Vallecula 5 (5%)  
Pharyngeal Wall 3 (3%)  
Retromolar Trigone 1 (1%)  
     
    *One patient had a lesion on both the upper lip and oral tongue.

Squamous cell carcinoma was the most common histological type in our study. Among 92 cases of squamous cell carcinoma two were basaloid squamous cell carcinoma and one was sarcomatoid squamous cell carcinoma. Verrucous carcinoma was the next common type, found in 4% of patients. Adenoid cystic carcinoma was found in 3%. One patient had Basal cell carcinoma of the lip.   The Majority of the tumors in our study were well differentiated (47%).


Discussion:

Oral cancer is the most common cancer in India accounting for 50-70% of total cancer mortality. Though it is more common in males, the rate is increasing in females also. In our study, the majority (77%) of the patients were males. Only 23% were females. Similar sex distribution has been reported by many authors.

In a study by Patel MM,  et al,1 at Surat, Gujarat, 75% of the patients were males. Mehrotra Ravi, et al,2 from Allahabad, India reported a male: female ratio of 3.27:1. Iype EM, et al,3 from Trivendrum, Kerala found a higher preponderance in males (70%) compared to females (30%).  Wahid A, et al,4 from Abottabad, Pakistan found 60% males and 40% females. Durazzo MD, et al,5 from Brazil reported 31.8% cases were females.

The higher incidence of oral and oropharyngeal malignancies in males may be due to the high rate of tobacco and alcohol consumption among males. Moreover, tobacco is consumed in both smoking and chewing form in males, whereas in our society, females do not usually indulge in smoking. The difference can also be attributed to more males seeking early medical consultation.2

Mean age at presentation in our study was 60 years. Maximum numbers of patients were in the age range of 50-59 years. The youngest patient in our study was 30 years old. Only 4% of the patients were less than 40 years of age.  Patel MM, et al,1 reported 12.9% of oral and oropharyngeal malignancies were below 35 years of age, 23.8% between 35 and 45, and 63.3% cases over 45 years of age.

In a study by Mehrotra Ravi, et al,2 the maximum incidence was in the 50-59 years of age range. Iype EM, et al,3 found 2.8% of the oral cancer in young patients below 35 years of age. According to Wahid A, et al,4 in Pakistan, the most common age group affected in oral cavity squamous cell carcinoma was 41-50 years (38%), followed by 51-60 years(34%).  In a study by Durazzo MD, et al,5  the mean age was 57.4 years.  Only 8.6 % of the patients were 40 years or less.

Most of the studies found the maximum incidence of oral and oropharyngeal malignancies in people over 50 years of age but  the younger age group is not completely spared.  The increasing incidence of these cancers in the younger age group can be correlated to the trend of tobacco and alcohol consumption in the young population.

In our study, out of a total  of 100 patients, 58% patients were smokers.  52% were consuming smokeless tobacco in the form of pan or gutkha.  37% of patients were consuming alcohol.  44% were using alcohol as well as tobacco, either smoking or chewing.  Smoking and alcohol consumption were seen only in males.  None of the females were smoking or consuming alcohol.  Tobacco chewing was the only habit found in 15 out of 23 female patients in our study.

In a study by Iype, et al,3 56.4% of the patients were habituated to either tobacco chewing, smoking or alcohol.  In the study of Durazzo MD, et al,4 tobacco smoking was identified in 80.8% of the patients.  Alcohol consumption history was retrieved in 56.6% of the patients.

The most common symptom in our study was an oral lesion which was seen in 71% of the patients.  Durazzo, et al,5 from Brazil also found oral lesions to be the most common presenting symptom in their study (88%).  Any growth or ulcer in the oral cavity should be looked at with a high index of suspicion and should lead to further investigation.

In our study, the buccal mucosa was the most common site involved (22%) followed by oral tongue (21%) and base of tongue (10).  Tonsil (9%), lip(7%), floor of mouth, hard palate and alveolus (6% each) were the next common sites involved. Vallecula (5%), pharyngeal wall (3%) and retromolar trigone(1%) were the other sites involved in the study.

In the study by Patel MM and Pandya AN,1 conducted at Surat, Gujarat, the anterior 2/3 of the tongue was the most common site (23.02%).  Next common was the posterior 1/3 (19.64%), followed by the alveolus, lips and cheeks. Mehrotra R, et al,2 in their study found the tongue to be the most common site (42.57%) followed by the cheek in 19.14%.  Iype EM, et al,3 found the tongue as the most common site (52%) followed by cheek(26%), alveolus (10%), palate (4.5%), lip (2.3%) and floor of mouth (1.9%).

Durazzo MD, et al,5 in their study found 55.6% of patients having cancer of the tongue and floor of mouth.  Walid A, et al,4 in their study at Abottabad, Pakistan, reported a maximum number of oral cancer in the buccal mucosa (34%).  Other sites were the lip (26%), tongue (21%) and gums (19%).  Ahmed F and Islam KM,6 from the Department of Pathology, Dhaka Medical College, Bangladesh , found the cheek to be the most common site, the next being the anterior 2/3 of of the tongue.
It is observed in various studies that anatomically more anterior parts (buccal mucosa, anterior 2/3 of the tongue, alveolus, lips, and base of tongue) are the frequently involved sites in oral and oropharyngeal malignancies.  This could be due to the long duration of contact with the carcinogens in tobacco and alcohol.

In our study, 92% of the cases had squamous cell carcinoma, out of which two were basaloid squamous cell carcinoma and one was sarcomatoid squamous cell carcinoma.  4% were verrucous carcinoma, 3% adenoid cystic carcinoma and 1% had basal cell carcinoma.

In the study of Patel, et al,1 all of the 504 patients in the study had squamous cell carcinoma.  Mehrotra and colleagues2 also found squamous cell carcinoma as the most common histological variety, comprising of 85.12% of oral and 97.5% of oropharyngeal malignancies. In a study by Iype and coworkers,3 squamous cell carcinoma was the most frequent type (72%).  3.8% had minor salivary gland tumors , 1.9% had soft tissue sarcomas. 6% had nonspecific malignancies.  Durazzo MD, et al,5 from Brazil also found squamous cell carcinoma was the most frequent histological type and was present in 90.3% of patients included in their study.  Glandular carcinoma was found in 4% of them.

In our study, 47% of the tumors were well differentiated, 42% were moderately differentiated and 5% were poorly differentiated.  In the study by Patel MM,1 60.12% of the tumors were well differentiated, 38.7% were moderately differentiated and 1.18% were poorly differentiated. Mehrotra R, et al,2 also observed a maximum number of well differentiated squamous cell carcinoma.  Iype EM, et al,3 found well differentiated squamous cell carcinoma in 52.6% cases.

Conclusion:

Carcinoma of the oral cavity and oropharynx is predominantly a disease of men.  It usually occurs after middle age, but the younger age group is not completely spared, due to the increase in the habit of consumption of tobacco and alcohol in the younger population.  Anatomically, the anterior portion of the oral cavity is commonly involved possibly due to the longer duration of contact with the carcinogens in tobacco and alcohol.  Squamous cell carcinoma is the most common histological type of malignancy in the oral cavity and oropharynx.

 
References:

1. Patel MM and Pandya AN. Relationship of oral cancer with age, sex, site distribution and habits. Indian J Pathol Microbiol 2004; 47(2): 195-197.   View Abstract

2. 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 Sep;57(9):400-4.  View Abstract

3. 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 Jul-Sep;47(3):171-6.  View Abstract

4. 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 Jan-Mar;17(1):65-6.  View Abstract

5. Durazzo MD, de Araujo CE, Brandão Neto Jde S, Potenza Ade S, Costa P, Takeda F, Bianchi C, Tavares MR, de Britto e Silva Filho G, Ferraz AR. 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 Aug;60(4):293-8. Epub 2005 Aug 29.  View Abstract

6. Ahmed F, Islam KM. Site predilection of oral cancer and its correlation with chewing and smoking habit--a study of 103 cases. Bangladesh Med Res Counc Bull. 1990 Jun;16(1):17-25.  View Abstract

7.  Chhaya VA, Sinha V, Rathor R, Modi N, Rashmi GS, Parma V, Chhaya R. Oral Submucus Fibrosis -Surgical Treatment with CO2 Laser. World articles in ENT. Volume 3(2) 2010   View Article

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