ABSTRACT

Corresponding Author:
Dr. Imrinder Kaur,
D-10, Medical Campus,
Rajindra Hospital Patiala, Punjab.
E-mail: imrinder@hotmail.com

ABSTRACT

BACKGROUND

Head and neck cancer is one of the most common cancers worldwide, and more than 90% of these tumours are squamous cell carcinomas. Oral cancer is the most common form of cancer and of cancer-related deaths in men in India. Tobacco and alcohol are the two strongest aetiological factors responsible for the development of head and neck squamous cell carcinoma, but in contrast younger patients often do not present these traditional risk factors, which leads to suspect other potential risk factors. Its high risk in the Indian subcontinent is related to the popularity of pan-tobacco (a combination of betel leaf, lime, areca nut and sun-cured tobacco) chewing in the region.

The objective of this study was aimed at analysing the incidence, aetiology and clinical presentation of head and neck carcinoma in our population and to evaluate the pathological findings and also the TNM staging in patients with head and neck carcinoma.

MATERIALS AND METHODS

We conducted a study on 150 diagnosed cases of head and neck cancer in the ENT Department of Government Medical College/Rajindra Hospital, Patiala, Punjab, India. Detailed history of the selected patients was taken and tumour data including site, subsite, grade and TNM stage were collected.

RESULTS

The maximum prevalence of patients with head and neck cancer was seen in the fifth decade (34.66%) followed by sixth decade. The male-to-female ratio was 70:30. The highest incidence was in the persons belonging to labourer group followed by farmers and businessmen. Chronic smoking and drinking played a major role in causing cancer in these groups. Most frequent site involved was oral cavity (39.33%) followed by oropharynx (23.33%). In the oral cavity, tongue was the most common site followed by buccal mucosa, whereas in oropharynx base of tongue was the most common subsite followed by retromolar trigone. Maximum incidence of hypopharyngeal carcinoma, especially in the post-cricoid region was seen in female patients (84.6%). Oral cavity cancers were most commonly presented with mass/growth followed by non-healing ulcers, whereas oropharyngeal cancers were most commonly presented with dysphagia followed by odynophagia. Majority of the patients presented with either well-differentiated or moderately differentiated squamous cell carcinoma. Maximum number of patients presented with early tumour staging: T₁ and T₂.

CONCLUSION

This study was aimed at analysing the age, sex distribution, role of aetiological factors, extent and clinical presentation including site, subsite, TNM stage and histopathological grading. In non-smoking and non-drinking patients, sharp tooth, environmental smoke and occupational exposure may contribute to squamous cell carcinoma. High index of suspicion was required to diagnose these lesions early, even when history of smoking and drinking was absent.

KEYWORDS

Head and Neck, Squamous Cell Carcinoma, Oral Cavity.

BACKGROUND

Head and neck cancer is one of the most common cancers found worldwide; more than 90% of these tumours are 

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DISCUSSION

In this study, maximum prevalence of patients with incidence of head and neck cancer was seen in the fifth decade (34.66%) followed by sixth decade. The incidence of head and neck cancer decreased below the age of 30 years and above the age of 60 years. Our study was compatible with the study by Sharma et al.¹⁵ Our study comprised of 150 patients, of which 105 patients were men and 45 patients were women. These findings were in concordance with the results of various previous studies conducted in India. In our study, the most frequent site involved was oral cavity, subsite was the oral tongue 16.66% followed by buccal mucosa 14%, floor of mouth and lip. Our study was congruent with the studies conducted by Dahlstrom et al,¹⁶ Wiseman et al¹⁷ and Harris et al.¹⁸ In addition, we found that among the oral tongue growths, lateral border of tongue was most commonly involved. The dental professionals as well as ENT surgeons should be cognizant of the increasing incidence of oral tongue SCC and should consider oral tongue SCC, while evaluating patients with tongue lesions even when history of smoking and alcohol abuse was not present. The most common oropharyngeal subsite in our patients was the base of the tongue 11.33% followed by retromolar trigone 6%. Dahlstrom et al¹⁶ and Wiseman et al¹⁷ also found the most common oropharyngeal subsite to be the base of the tongue followed by tonsillar fossa. First symptom in cancer oropharynx was difficulty in swallowing. Other presenting symptoms were trismus and cervical lymphadenopathy. SCC was most commonly seen in oropharynx, dominated by moderately differentiated carcinoma. Hypopharyngeal carcinoma constituted 14.66% of head and neck cancer. Cancer in most of the cases was seen arising from pyriform fossa (9.33%) and post-cricoid (5.33%) region. Stefani and Eells¹⁹ recorded pyriform fossa to be the most common site of origin. The development of hypopharyngeal cancers in the post-cricoid area in women in the age group of 30 to 50 years without a history of tobacco or alcohol use was associated with Plummer-Vinson syndrome, also termed as Paterson-Brown-Kelly syndrome.^20-22 This syndrome was characterised by hypopharyngeal webs, dysphagia, weight loss and iron-deficiency anaemia. A substantial proportion of hypopharyngeal cancers could be attributable to occupational exposures.²³ The most common form of clinical presentation in our present cases was dysphagia, which was seen in 19 of the 22 cases. Larynx was involved in 5.33% of the patients with head and neck cancer in our study. Jussawalla et al²⁴ have correlated the development of laryngeal carcinoma with smoking habits. In a study by Sharma et al,¹⁵ the prevalence of laryngeal SCC constituted 16.7% of the total HNSCC. SCC was predominant. Malignancy involving cervical lymph nodes was observed in eight cases (7.33%), of which five patients had occult primary and two had lymphoma. Primary site in case of metastatic carcinoma of cervical lymph nodes was nasopharynx in 37.5% of the patients. In this study, the incidence of cancer in the salivary glands was 3.33% [three cases] of the patients with head and neck cancer. In our study, parotid was commonly affected. In a study conducted in Manipur, Bhatia and Jha²⁵ reported incidence of carcinoma of the salivary gland to be 2.9% of the patients with head and neck cancer. Nasopharynx constituted 1.33% of the patients with head and neck cancer. Sharma et al¹⁵ found nasopharyngeal carcinoma in 1.05% of the patients. In our study, women above 60 years of age presented with complaint of nasal obstruction and nasal bleeding. In our study, nasopharyngeal carcinoma involved roof of nasopharynx followed by fossa of Rosenmuller. All the cases belonged to SCC and both were moderately differentiated. Thyroid was involved in 1.33% of the patients with head and neck cancer. In our study, women dominated the incidence of thyroid carcinoma. In this study, incidence of nose and paranasal sinuses was 2%. Nasal obstruction was the most common complaint because of the presence of mass in nasal cavity. In our study, only 0.66% of the patients with head and neck cancer showed symptoms involving ear and the patients presented with growth on pinna, whereas Bhatia and Jha²⁵ found it to be 0.8% in a study conducted by them in Manipur. In this study, incidence of oesophagus carcinoma was 0.66%. Wynder et al²⁶ concluded that excessive tobacco, alcohol consumption and dietary deficiencies can cause oesophagus cancer. In this study, patients had SCC of moderately differentiated type.²⁶ Carcinoma of mandible constituted 0.6% of the patients with head and neck cancer. In our study, oral cavity cancers most commonly presented with mass/growth (84%) followed by non-healing ulcer (27.3%) and oropharyngeal cancers most commonly presented with dysphagia (65.7%) followed by odynophagia (57.1%). Strong suspicion was required for early diagnosis and management, even when patient was not having any history of tobacco or alcohol abuse. Dahlstrom et al¹⁶ observed that majority of patients presented with either moderately differentiated or well-differentiated SCC. In our study, it was observed that majority of patients presented with either well-differentiated or moderately differentiated SCC. The degree of differentiation was considered as one of the important prognostic factors in head and neck cancers. Well-differentiated SCC showed good prognosis and poorly differentiated cancers showed worst prognosis. In this study, we found that maximum patients with oral cavity SCC (87.28%) presented with early tumour staging, that is T₁ and T₂. In oropharyngeal SCC, maximum patients (88.5%) presented with tumour staging—T₁ and T₂. Harris et al¹⁸ also reported maximum number of patients (72%) who presented with T₁ and T₂ stage %). We also acknowledge some limitations to our study. One limitation of our study was the relatively small patient cohort. Second limitation was that we did not include HPV status in our patients. High index of suspicion was required to diagnose these lesions early, even when history of smoking and drinking was absent.

CONCLUSION

This study was aimed at analysing the age, sex distribution, role of aetiological factors, extent and clinical presentation including site, subsite, TNM stage and histopathological grading. In non-smoking and non-drinking patients, sharp tooth, environmental smoke and occupational exposure may contribute to squamous cell carcinoma. High index of suspicion was required to diagnose these lesions early, even when history of smoking and drinking was absent.