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Gowthami M R, Veerabasappa, and Surhonne: Histopathological spectrum of tumor and tumor like lesions of oral cavity and oropharynx in t ertiary care hospital


Introduction

According to World Health Organization, carcinoma of oral cavity in males in developing countries, is the sixth commonest cancer, while in females, it is the tenth commonest site of cancer.1 It typically occurs in elderly men during the fifth through eighth decade of life and is rarely seen in young people.

In India, head and neck cancers (HNCA) account for 30-40% cancers at all sites, out of which 9.4% being oral cancers. Oral cancers are the most common among head and neck malignancies. 2, 3 It is the sixth most common cause of death in males and seventh in females.3

Although globally oral cancer represents an incidence of 3% males and 2% females of all malignant neoplasms, it has one of the lowest survival rates – 50% within a 5 year period.4

Many studies have shown that several factors lead to increase in the relative incidence of oral cancer. These include5, 6 Age and gender , Habits (Tobacco and alcohol) – dose response relations were observed for the frequency and duration of smoking and alcohol.7 Orodental factors (Poor oral hygiene, improperly fitting dental prostheses, defective dental restorations and mal-aligned or sharp teeth) and Viruses like Human Papilloma Virus, Herpes Simplex Virus, Epstein-Barr Virus.

WHO classification of tumours of oral cavity and oropharynx 8 (2005) includes major tumours like, Surface epithelial tumours (Squamous cell carcinoma Lymo-hoepithelioma like carcinoma), salivary gland tumours (Salivary gland carcinomas and adenomas), Soft tissue tumours, Haematolymphoid tumours And Mucosal malignant melanoma.

The gold standard for the assessment of oral potentially malignant lesions is microscopic evaluation of haematoxylin and eosin stained sections for the presence of architectural and cytological changes, which are generally referred to as epithelial dysplasia. 9

This study was conducted to study the histopathological changes in tumour and tumour like lesions of oral cavity and oropharynx.

Aim and Objective

To study the histopathological changes in tumor and tumor like lesions of oral cavity and oropharynx

Material and Methods

Present study is a prospective study carried out in department of pathology of a tertiary health care centre. Patients with oral cavity and oropharynx lesions were included in the study. Total 100 biopsies and resected specimens were received during study period of 2 years.

Inclusion criteria

Patients with lesion in oral cavity and oropharynx, undergoing biopsy or surgical treatment at tertiary health care center.

Exclusion criteria

  1. All lesions involving teeth 2 The patients not willing to participate in the study

Study was approved by ethical committee of the institute. A valid written consent was taken from patients after explaining study to them.

Data was collected with pre tested questionnaire. Data included sociodemographic data of the patient, clinical history. A through clinical examination was done. All biopsies and resected specimens were received in 10% formalin. Gross findings were noted. Tissue processed and stained with Haematoxylin and Eosin.

Haematoxylin and Eosin staining method

  1. Sections deparaffinised by putting in xylene

  2. Hydrated by using descending grades of alcohol (100%, 90%, 70% for 1 minute each

  3. Washed with distilled water Stained 4-8 minutes in Harris hematoxylin solution

  4. Washed in running tap water for 1 hour until the blue colour developed

  5. Stained in eosin for 25 to 45 seconds

  6. Dehydrated using ascending grades of alcohol (70%, 90%, 100% for 1 minute each

  7. Cleared with xylene Sections then mounted in DPX

Histopathological diagnosis was made. Patients with tumor and tumor like lesions were studied. Data was analyzed with appropriate statistical tests.

Results

Present study includes 100 cases of oral cavity and oropharyngeal lesions out of which 19% were inflammatory lesions, 10% tumor like lesions, 4% benign lesions, 4% premalignant lesions and 63% malignant lesions.

The patients’ age in our study ranged from 6 to 80 years with a mean age of 45.6 years. Male preponderance was seen in malignant lesions with a male to female ratio of 1.7:1.

Among malignant lesions in our study, 60.3% had history of tobacco consumption, 17.5% consumed both alcohol and tobacco, 9.5% were alcoholics and 12.7% patients did not have any habits. So, most common risk factors were tobacco consumption and alcohol. They carried a definite risk for the development of malignant lesions. Buccal mucosa was the most common site of malignant lesions. Even benign and premalignant lesions had buccal mucosa as the most common site. Tonsil was the most common site among inflammatory lesions and lip among tumour like lesions.

Out of 63 cases of malignant lesions in our study, 41 cases underwent incisional biopsy, 6 cases underwent excisional biopsy and 16 cases underwent resections with or without modified radical neck dissections.

The predominant tumour-like lesion in our study was mucocele seen in 6 cases (60%) out of 10 cases (Figure 2). The other cases encountered were pyogenic granuloma in 2 cases (20%) and hamartoma in 2 cases (20%). Different types of mucoceles in our study were 4 cases (40%) were retention mucoceles, 1 case was extravasation mucocele (10%) and 1 case was ranula (10%).(Table 1)

Among 4 premalignant lesions 1 case was each of keratosis with mild atypia, keratosis with moderate atypia, submucous fibrosis and verrucous hyperplasia comprising of 25% each. (Table 3)

Out of 63 cases of malignant lesions in our study squamous cell carcinoma (Fig 4) was the most common histological type accounting for 60 cases (95.2%). The other 3 cases were, one case each of mucoepidermoid carcinoma, basal cell carcinoma and carcinosarcoma constituting 1.6% each. (Figure 1)

Out of 60 cases of Squamous cell carcinoma, majority were well differentiated type seen in 31 cases (51.67%) followed by moderately differentiated in 23 cases (38.33%) and 6 cases (10%) were poorly differentiated. (Table 4 )

In our study 14 cases of Squamous cell carcinoma underwent resections with modified radical neck dissections. Out of these the extent of involvement is shown in Table 5

Out of 14 resected cases of Squamous cell carcinoma,1 case (7.14%) belonged to T1N0M0 (Stage I), 5 cases (35.71%) to T2N0M0 (Stage II). 3 cases (21.43%) were of Stage III 1 case of T2N1M0 , 1 case of T3N1M0 and 1 case of T1N1M0. The rest 5 cases (35.71%) belonged to Stage IV wherein there were 2 cases of T2N2bM0, 1 case of T4aN2aM0, 1 case of T4aN1M0 and 1 case of T4aN1M0. (Table 6 )

Table 1

Histopathology oftumour-like lesions of oral cavity and oropharynx

Histopathological type No. %
Mucocele 6 60
Hamartoma 2 20
Pyogenic granuloma 2 20
Total 10 100
Table 2

Histopathology of benign lesions of oral cavity andoropharynx

Histopathological type No. %
Cavernous hemangioma 1 25
Fibroma 3 75
Total 4 100
Table 3

Histopathology of premalignant lesions of oralcavity and oropharynx

Histopathological type No. %
Keratosis with mild dysplasia 1 25
Keratosis with moderate dysplasia 1 25
Submucous fibrosis 1 25
Verrucous hyperplasia 1 25
Total 4 100
Table 4

Grading of Squamous cell carcinoma

Grade Squamous Cell Carcinoma Percentage
Well differentiated (Grade 1) 31 51.67
Moderately differentiated (Grade 2) 23 38.33
Poorly differentiated (Grade 3) 6 10
Total 60 100
Table 5

Resections with modified radical neck dissection andthe extent of involvement

Involvement by tumour Number of cases
Lymph node metastases 3
Lymphovascular invasion + Lymph node metastases 1
Lymph node metastases + Soft tissue invasion 1
Lymphovascular invasion + Minor salivary gland + skeletal muscle invasion 1
Lymph node metastases + Overlying skin+ soft tissue invasion 2
No involvement of regional lymph nodes and surrounding structures 6
Total 14
Table 6

Staging of resected tumors

Staging Squamous Cell Carcinoma
Number Percentage
I 1 7.14
II 5 35.71
III 3 21.43
IV A 5 35.71
B 0 0
C 0 0
Total 14 100

Figure 1

Histopathology of malignant lesions of oral cavity and oropharynx

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Figure 2

Photomicrograph (20x, H&E) of Mucocele of lip shows extravasated mucin pool along with mixed inflammatory cell infiltrate. H & E- Hematoxylin & Eosin

https://s3-us-west-2.amazonaws.com/typeset-media-server/b79d1d63-5124-4d2e-adf6-5db8885e4b50image2.png

Figure 3

Specimen of resection of tumour of right buccal mucosa with modified radical neck dissection.

https://s3-us-west-2.amazonaws.com/typeset-media-server/b79d1d63-5124-4d2e-adf6-5db8885e4b50image3.png
Figure 4

Photomicrograph (10x, H & E) shows an infiltrating well differentiated SCC of leftbuccal mucosa composed of nests of tumour cells along with well formed keratin pearls scattered throughout the tumor. H & E- Hematoxylin & Eosin; SCC- Squamous Cell Carcinoma

https://s3-us-west-2.amazonaws.com/typeset-media-server/b79d1d63-5124-4d2e-adf6-5db8885e4b50image4.png

Discussion

In our study the premalignant lesions were seen predominantly in the age group 61-70 years.similar findings were seen in a study by Khan Y et al 10 and Atram MA 11 et al where they found the maximum incidence of premalignant lesions in the age group 40-60 years.

Present study is in concordance with studies by Misra V et al, 12 Khandekar SP et al 13 and Gupta M et al 14 where peak incidence of malignant lesions was seen in the age group 51-60 years.

These studies found the maximum incidence of oral malignancies in people over 50 years of age in concordance with the present study. Hence, screening programs targeting men over 50 years, would help in early diagnosis of oral malignancy.

Histopathological spectrum of tumor like lesions

The predominant tumor-like lesion in our study was mucocele seen in 60% cases. Our study is comparable with the study by Atram MA et al 11 where mucocele was the most common tumour like lesion found in 50% cases. In a study by Khan Y et al, 10 Pyogenic granuloma was the most common lesion found in 53.6% cases.

Histopathological spectrum of benign lesions

The most common benign lesion in our study is fibroma seen in 75% cases. In studies by Khan Y et al 10 and Atram MA et al 11 the most common benign tumor was hemangioma.

Histopathological spectrum of premalignant lesions

75% cases were leukoplakia in our study and formed the predominant premalignant lesions which is comparable with study by Nayak P et al 15 where 80% cases were leukoplakia.

Histopathological spectrum of malignant lesions

The most common malignant lesion was Squamous cell carcinoma in our study seen in 95.2% cases.Our study is in concordance with studies by Gupta M et al 14 and Nayak P et al 15 which showed Squamous cell carcinoma as the commonest histological type among malignant lesions in 98.18% and 98% respectively.

Grading of oral SCC   

Well differentiated SCC was the most common type in our study seen in 51.67% of SCC.The present study is in concordance with studies done by Khan Y et al 10 and Rai HC et al 16 where majority of cases were well differentiated SCC seen in 47.61% and 51% of SCCs respectively.

Tumor clearance

Out of 16 resected specimens, the tumor involved resected margins in 7 cases (43.7%) in our study with a tumor clearance of 56.3%. Our study has lower tumor clearance as compared to the study by Jerjes et al 17 where tumour clearance was seen in 93% cases.

Resections with modified radical neck dissection

In our study 14 cases (23.3%) out of 60 cases of Squamous cell carcinoma underwent resections with modified radical neck dissections. 7 cases (11.6%) out of 60 Squamous cell carcinomas had lymph node metastases and 2 cases (3.3%) showed lymphovascular invasion.

Our study showed a lower incidence of lymph node metastases (11.6%) and lymphovascular invasion (3.3%) compared to a study by Beggan C et al 18 which showed nodal metastases in 17 cases (29.3%) and lymphovascular invasion in 11 cases (19%).

Staging of tumours

In our study 35.71% of patients belonged to Stage II and 35.71% to Stage IV. In a study by Suresh TN et al19 43.8% of patients belonged to Stage IV which is slightly more than that in our study and 21% of patients belonged to Stage II. Whereas Stage I (5.7%) and Stage III (29.5%) in our study was comparable with Stage I (7.14%) and Stage III (21.43%) of their study.

Conclusion

Histopathological examination of lesions of oral cavity and oropharynx is gold standard. The present study on 100 oral cavity and oropharyngeal lesions showed predominance of malignant lesions seen in 63% cases. The most common malignant lesion in our study was Squamous cell carcinoma.

Source of Funding

None.

Conflict of Interest

None.

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