Squamous cell carcinoma of buccal mucosa: Prevalence of clinicopathological pattern and its implications for treatment

Ramasamy Padma; Sathish Paulraj; Sivapatham Sundaresan

doi:10.4103/srmjrds.srmjrds_73_16

ORIGINAL ARTICLE

Year : 2017 | Volume : 8 | Issue : 1 | Page : 9-13

Squamous cell carcinoma of buccal mucosa: Prevalence of clinicopathological pattern and its implications for treatment

Ramasamy Padma, Sathish Paulraj, Sivapatham Sundaresan
Department of Medical Research, SRM Medical College Hospital and Research Centre, SRM University, Kanchipuram, Tamil Nadu, India

Date of Web Publication

30-Mar-2017

Correspondence Address:
Ramasamy Padma
Department of Medical Research, SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Kanchipuram - 603 203, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/srmjrds.srmjrds_73_16

Abstract

Background: In developing countries, oral squamous cell carcinoma is a leading cause of mortality due to late diagnosis. Hence, the aim of the study was to analyze the clinical and pathological presentation of buccal mucosa carcinoma patients. Materials and Methods: A case series study was conducted in regional cancer centre, Tamil Nadu. Demographic and clinical details were collected from medical registries between 2013 and 2015. Results: The present study consists of 198 cases which comprised 125 (63.1%) male and 73 (36.9%) female. The mean age of the cases was 54.16 ± 17.25 years. Histopathology reports showed most frequency of well-differentiated buccal squamous cell carcinoma 98 (49.5%) and followed moderate 98 (34.3%) and poorly differentiated 32 (16.2%). Clinical tumor nodal metastasis reports revealed 168 (85%) of advanced clinical stage (III and IV) of buccal mucosa carcinoma, whereas only 30 (15%) was presented at early stage (I and II) of disease. Based on the clinical and histopathological analysis, 86 (43.4%) cases were fit for surgery and followed by adjuvant chemo- - and radio-therapy. Of 198 cases, the most common clinical complaints were identified with 73 (38%) pain and followed by 47 (28%) bleeding, may be due to unawareness or ignorance of disease. Conclusion: The study concluded that most of the cases had diagnosed in advanced stage of tumor with severe pain and bleeding. Hence, further studies warrant on awareness of clinical symptoms and also to analyze the risk factors for delay diagnosis in Tamil Nadu population, which might reduce morbidity and mortality.

Keywords: Age, diagnosis, histopathology, pain, squamous cell carcinoma, tumor nodal metastasis stage, ulceration

How to cite this article:
Padma R, Paulraj S, Sundaresan S. Squamous cell carcinoma of buccal mucosa: Prevalence of clinicopathological pattern and its implications for treatment. SRM J Res Dent Sci 2017;8:9-13

How to cite this URL:
Padma R, Paulraj S, Sundaresan S. Squamous cell carcinoma of buccal mucosa: Prevalence of clinicopathological pattern and its implications for treatment. SRM J Res Dent Sci [serial online] 2017 [cited 2023 Mar 31];8:9-13. Available from: https://www.srmjrds.in/text.asp?2017/8/1/9/203489

Introduction

Globally, oral cancer is the sixth most common cancer.^[1] In India, oral cancer was highly preventable because over 80% caused by smoking, pan chewing, and alcohol drinking risk habits.^[2] Oral squamous cell carcinoma develops from premalignant conditions includes leukoplakia, erythroplakia, oral lichen planus, and submucous fibrosis of the oral cavity. Leukoplakia was known to occur at almost all places in oral cavity; high frequency reported at buccal mucosa and mandibular mucosa.^[3]

In South India, buccal mucosa carcinoma was the most common oral subsite, and about 70% of the cases were presented at advanced stage of disease.^[4] About 30% of OSCC patients usually wait for >3 months before consulting medical/dental professional after self-discovery of signs and symptoms of oral cancer.^[5] A great challenge is that though oral subsites practically a visible lesion could not detected early enough for successful treatment due to ignorance as a minor oral disease, for example, trauma, infective process, and nondangerous dental conditions.^[6],[7]

Although advance technique was available, clinical and histopathological methods are classical methods still and stay as most important guide for treatment stratification in clinical practice. The survival time of the oral cancer patients is strongly associated with the tumor nodal metastasis (TNM)-stage and differentiation of tumor.^[8] The most widely used TNM classification system for describing the anatomical extent of the disease is the Union for International Cancer Controls (UICC) system, which grades primary tumor size and invasion features (T), regional lymph node spread (N), and the presence of distant metastasis (M). By morphological assessment, tumors were classified based on the cancer cells differentiation into well-, moderately, and poorly differentiated carcinomas. There are many classifications available. The WHO classification is the widely used classification system in clinical practice.^[9],[10]

In India, several reports are available for the prevalence of buccal mucosa carcinoma, but none of them address buccal mucosa carcinoma, particularly in Tamil Nadu. Hence, the aim of our study was to analyze the clinicopathological presentation in Tamil Nadu.

Materials and Methods

The study was conducted between the year of 2013 and 2015 to analyze the clinical and histopathological features of buccal mucosa carcinoma patients in Regional Cancer Centre, Arignar Anna Memorial Cancer Hospital, and Research Centre, Kanchipuram, Tamil Nadu.

The Institutional Ethical Committee and directorate of medical education, Tamil Nadu, clearance was obtained to conduct the study (No. 24984/2013).

Data collection

A total of 198 buccal mucosa carcinoma cases were diagnosed from 2013 to 2015. Subject's demographic, clinical details, and also clinical symptoms were collected from medical registries. Clinical TNM staging according to UICC classification and histopathological grading based on the WHO grading system was collected.

Cases inclusion and exclusion criteria

Clinical and histopathologically confirmed primary buccal mucosa carcinoma cases were included in the study, whereas precancerous conditions and other oral subsites were excluded from the study.

Statistical analysis

The statistical analysis software SPSS (IBM, Chicago, IL, USA) for windows version 16 was used to obtain mean and standard deviation for quantitative variables and the absolute and relative frequencies of the qualitative variables.

Results

A total of 198 buccal mucosa carcinoma cases were diagnosed in regional cancer centre of Tamil Nadu between the periods of 2013 and 2015. [Table 1] shows the description of demographic details. Of 198 study cases, the male cases 125 (63.1%) were found to be predominant than female 73 (36.9%) in the ratio of 1.7:1. Among them, 122 (61.6%) cases were married and lived with family, remaining 76 (38.4%) cases might not have relatives to take care because they live as single/widow. The most of the cases were Hindus 83 (41.9%), followed by Muslims 65 (32.9%), and Christians 50 (25.2%). However, 146 (73.7%) cases were nonvegetarian habitual. An interesting finding is that 9 (4.5%) had family history of oral cancer.

Table 1: Baseline demographic characteristics of buccal mucosa carcinoma cases

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The cases were presented with age range from 21 to 88 years, and mean age of the cases was 54.16 ± 17.25 years. The majority of the cases 64 (32%) were <60–79 years age groups and followed by 59 (30%) of 40–59 years and 57 (29%) of ≥80 years age group, whereas 18 (9%) cases were young adults who were <40 years of age groups [Table 1].

[Table 2] shows the clinical TNM stage and histopathological characteristics details. In the study, most of the cases 129 (65.2%) were indentified with left side disease. In histological analysis, all the cases were diagnosed with squamous cell carcinoma based on the score of degree of keratinization, nuclear pleomorphism, and number of mitosis/high-power field. The most frequent cases histopathological diagnosis was Grade I, well-differentiated squamous cell carcinoma 98 (49.5%), followed by Grade II, moderate 68 (34.3%), and Grade III, poorly differentiated 32 (16.2%) buccal mucosa carcinoma.

Table 2: Clinical profile of buccal mucosa carcinoma cases

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[Table 2] shows the pathological report of tumor stage, size, depth, nodal, and metastasis status of cases and also clinical TNM stage details. The tumor status was T1 in 14 cases (7.1%), T2 in 35 cases (17.7%), T3 in 67 cases (33.8%), and T4 in 82 cases (41.4%). 52 (26.3%) cases had tumor whose depth was >6 mm, and 123 (62.1%) cases tumor size was >4 mm. One hundred and sixty-eight cases (84.8%) had lymph nodes, and 57 (28.8%) observed with metastasis at diagnosis. Of 198 cases, 168 (85%) patients were diagnosed at advanced stage of buccal mucosa carcinoma which includes Stage III (13, 6.6%) and Stage IV (155, 78.3%). 30 (15%) of cases were diagnosed at early stage of disease which includes Stage I (13, 6.6%) and Stage II (17, 8.6%).

[Figure 1] shows the distribution of clinical symptoms identified at the time of diagnosis of buccal mucosa carcinoma. A total of 198 cases, 76 (38%) had complained with chronic pain followed by 47 (24%) complained of bleeding body fluid. Pain and bleeding were the most common clinical symptoms than other symptoms such as 36 (18%) ulceration (nonhealing wound), 17 (9%) had reduced mouth opening due to keratinization, 13 (7%) white or red spot, and 9 (4%) had only swelling (growth of abnormal tissue).

Figure 1: Distribution of identified clinical symptoms at diagnosis of patients

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Clinical and histopathological techniques are the gold standard methods of diagnosis and prognosis of oral cancer. Based on the clinical and histopathological analysis, further treatment was planned for cases. [Figure 2] and [Figure 3] show the distribution of treatment strategies according to degree of cellular differentiation and clinical stage of disease. Of 32 poorly differentiated cases, 29 (14.6%) were treated with surgery and further adjuvant chemo- and/or radio-therapy because of aggressiveness of disease. Clinically, 155 (78.2%) had diagnosed with advanced stage but 64 (32.3%) had undergone postoperative radio- and/or chemo-therapy because rest of the cases were not fit for surgery. Overall, 86 (43.4%) cases were treated with surgery, and further radio- and/or chemo-therapy and rest of the cases 112 (56.6%) were with radiotherapy alone/radio-chemotherapy.

Figure 2: Treatment strategies according to histopathology

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Figure 3: Treatment strategies according to clinical tumor nodal metastasis stage

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Discussion

Oral cancers are known to show geographical variation with respect to the age, site, sex, and stage of diagnosis. In South India, buccal mucosa carcinoma is most common cancer which is aggressive in nature.^[4] In the present study, a total of 198 cases were diagnosed with buccal mucosa carcinoma during the period of 2013–2015 in a single institute, Tamil Nadu. Similarly, a single institute study from Maharashtra reported that seventy cases were diagnosed with buccal mucosa carcinoma during 2008–2010.^[11] Therefore, the rising incidence trend of buccal mucosa carcinoma is seen recently.

The present study also reports a male predominance with male: female (1.7:1) ratio. In contrary, a reverse gender ratio was observed in India (Bengaluru) where male to female ratio was 1:2.0 and Mumbai cancer registries study also reported with 1:1.^[12],[13] However, Yeole, reported that on the whole of all six cancer registries in India, the increasing incidence of oral squamous cell carcinoma demonstrated predominance in males than females.^[14] A site-specific clinical audit reported with high frequency (55%) with right site habitual.^[15] In contrary, in the present study, 65.2% of cases had left side affected. Thus, in this region, most of the cases were left side habitual of tobacco in a different form.

Oral cancer is considered to be disease that occurs mainly in elderly between 50 and 70 years of age, and the mean age of occurrence of cancer in different parts of oral cavity is usually between 51 and 55 years in most of the countries.^[16] Similarly, the present study also reported the mean age as 54.16 years.

In general, >90% of oral cancer is squamous cell carcinoma. Kalyani et al. reported in her study that almost all cancer of oral cavity were squamous cell carcinoma.^[17] Similarly, the present study also reported with 100% of squamous cell carcinoma of buccal subsite. The present study revealed that most of the cases were diagnosed in advanced stage and as well-differentiated tumor. Similar results were presented by Agrawal and Rajderkar in a hospital-based study of Maharashtra, and also late presentation was reported in the cancer registry data of the state of Karnataka.^[18],[19]

In a case series, study of oral squamous cell carcinoma reported that most common clinical complaints were ulceration and swelling.^[20] In contrast, our study reports pain and bleeding of body fluid as most common clinical symptoms although other symptoms such as ulceration, swelling, and reduced mouth opening were also reported.

Oral cancer is most frequently diagnosed late in the course of the disease because affected persons fail to seek professional advice timeously, either because they do not understand the significance of early signs and symptoms or because they are ignorant of the health implications and also Panzarella et al. reported that cognitive and psychological variables were the major reasons for delay presentation.^[6],[21] However, further studies are needed to study reason factor for late diagnosis of buccal mucosa carcinoma.

Buccal mucosa carcinoma is aggressive in nature with high locoregional failure rate; need to treat with multimodality treatment.^[22] Zhang et al. showed his study that surgery with adjuvant chemotherapy and/or radiotherapy improved survival in oral squamous cell carcinoma.^[23] However, most of the oral cancer patients undergone with palliative treatment of chemoradiotherapy because advanced stage of diagnosis may not fit for surgery.^[24]

Conclusion

The study reports advanced stage of diagnosis and most of cases had well-differentiated tumor. Hence, it is an anticipated that early detection can reduce mortality of buccal mucosa carcinoma. The present study also reported that at advanced stage due to severe pain and infiltration condition, the cases were diagnosed due to unaware of early clinical symptoms of oral cancer or ignorance. Therefore, the study warrants implementing social awareness about early sign and symptoms education on self-oral screening methods so as to avoid the risk of late presentation of oral squamous cell carcinoma.

Acknowledgment

Our team would like to acknowledge and thank Arignar Anna Memorial Cancer Hospital and Research Centre, Kanchipuram, permission to conduct the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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