CLINICOPATHOLOGICAL SPECTRUM OF ORAL

CAVITY AND OROPHARYNGEAL MALIGNANCIES

By

DR. SHUBHA P. BHAT, M.B.B.S.

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfil lment

of the requirements for the degree of

Doctor of Medicine in

(PATHOLOGY)

Done under the guidance of DR. RAMESH NAIK C.N, MD

Professor, Department of Pathology, Fr.Muller Medical College

Mangalore

March-2010

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

Declaration by the Candidate

I hereby declare that the dissertation/thesis entitled

“CLINICOPATHOLOGICAL SPECTRUM OF ORAL CAVITY AND

OROPHARYNGEAL MALIGNANCIES” is a bonafide and genuine research

work carried out by me under the guidance of Dr. RAMESH NAIK C.N,

Professor, Department of Pathology, Father Muller Medical College,

Mangalore.

Date : DR. SHUBHA P. BHAT

Place : Mangalore

Certificate by the Guide

This is to certify that this dissertation entitled

“CLINICOPATHOLOGICAL SPECTRUM OF ORAL CAVITY AND

OROPHARYNGEAL MALIGNANCIES” is the bonafide work done by

DR. SHUBHA P. BHAT., Postgraduate resident in M.D. (Pathology), Father

Muller Medical College, Mangalore under my direct guidance and

supervision to my satisfaction in partial fulfillment of requirement for the

degree of M.D (Pathology).

Date : Dr. RAMESH NAIK C.N. M.D

Place : Mangalore Professor

Department of Pathology

Father Muller Medical College,

Mangalore

Endorsement By The HOD, Principal/

Head Of The Institution

This is to certify that DR. SHUBHA P. BHAT, Post Graduate Resident

in M.D. (Pathology) Father Muller Medical College, Mangalore has prepared

this dissertation entitled “CLINICOPATHOLOGICAL SPECTRUM OF

ORAL CAVITY AND OROPHARYNGEAL MALIGNANCIES” under the

guidance of Dr. RAMESH NAIK C.N, Professor, Department of Pathology,

Father Muller Medical College Mangalore.

DR. G.K.SWETHADRI DR. JAYAPRAKASH ALVA             M.D.,D.C.P M.D.,D.C.H

Professor and HOD Dean,

Department of Pathology, Fr. Muller Medical College,

Father Muller Medical College, Mangalore.

Mangalore.

Place : Mangalore Place: Mangalore

Date : Date:

COPYRIGHT

Declaration by the Candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation / thesis in print or electronic format for academic / research

purpose.

Place : Mangalore DR. SHUBHA P. BHAT

Date :

Acknowledgement

I thank almighty God for his blessings, which made this work possible and

whose grace strengthened me throughout my course.

My heartful thanks to my guide Dr. Ramesh Naik C.N M.D.,

Professor, Department of Pathology, for his suggestions and all facilities

provided for preparing this dissertation.

I express my deep gratitude to, Dr. G.K. Swethadri, Profesor & Head

of the Department, Dr. Hilda D’souza, Dr. Jayaprakash C.S., Dr. Indira.S.

Bangera, Dr. Nisha J Marla, Dr. Kirana Pailoor, Dr. Leena J.B,

Dr. Christol Moras, Dr. Safeena for their suggestions and willingness to help

me at all times.

I would like to thank Dr Jayaprakash Alva, Professor & Dean and

Dr Sanjeeva Rai, Professor & Chief of medical services, Father Muller Medical

college, Mangalore.

I thank Rev. Fr. Patrick Rodrigues, Director of FMCI and Rev. Fr. Stany

Tauro & Rev. Fr. Denis D’Sa Administrators for their support.

I thank Mrs. Sucharitha for helping me in statistics

I am grateful to all the patients who were part of this study. It is their

contribution that has made this study possible.

I am obliged by the help and co-operation provided by my colleagues

and friends.

This work would not have been complete without love and support of

my family.

I would like to express my thanks to all technical and office staff of Fr.

Muller Medical College and Staff of Microbits.

Date: Dr. Shubha P. Bhat.

Place: Mangalore

LIST OF ABBREVIATIONS USED

SCC - Squamous cell carcinoma

BCC - Basal cell carcinoma

Ca - Carcinoma

RMT - Retro molar trigone

HPV - Human Papilloma Virus

CMV - Cytomegalovirus

HIV - Huma Immunodeficiency Virus

ABSTRACT

BACKGROUND: In the developing world, oral cavity is the fourth commonest site of carcinoma

after lung, stomach and liver in males while in females it is the fifth commonest cancer

after cervix, breast, stomach and lung. The incidence from the National Cancer Registry

Project of the Indian Council of Medical Research confirmed the fact that oral cancer was

indeed a common form of cancer in India. Over the years, the incidence of oral cancers in

the population has increased many fold especially among younger generation, possibly

related to rising trend of paan masala and gutkha chewing, smoking, alcohol consumption

in the population. Though it is more common in males, the rate is increasing in females

also.

The purpose of the study is to determine the distribution of oral cavity and

oropharyngeal malignancies in relation to age, sex, site, histopathological type and

differentiation.

OBJECTIVES OF THE STUDY:

1. To study the histopathological pattern of oral cavity and oropharyngeal

malignancies.

2. To determine the distribution of oral and oropharyngeal malignancies in relation to age, sex and site.

3. To study the role of tobacco and alcohol in oral cavity and oropharyngeal malignancies.

METHODS:

This study was conducted in the Department of Pathology, Father Muller Medical

College Hospital, Kankanadi, Mangalore. Total 100 patients were studied. Patients

having complaint of growth in oral cavity and oropharynx were selected using purposive

sampling technique. Detailed history was recorded in a proforma, regarding age, sex,

presenting complaints, habits of chewing tobacco, pan and gutkha, habit of smoking and

consumption of alcohol. Thorough examination of oral cavity and oropharynx was done

and site of growth was noted. Biopsy was taken from the growth and was transferred to

the bottle containing 10% neutral formalin, processed, embedded in paraffin and 3-4 µ

thick sections were made. They were stained with Haematoxylin and Eosin stain. Special

stains were used as and when required. Histopathological diagnosis regarding type and

differentiation was made. Data was analyzed by chi-square test.

RESULTS:

Malignancy of oral cavity and oropharynx is more common in males than females.

Maximum number of cases presented between 50 and 59 years of age. Mean age at

presentation was 60 years. Youngest was 30 year old. Majority of patients were

agriculturists and manual labourers. 88% of patients were literates, while 12% were

illiterates. Maximum number of patients were from lower middle socioeconomic status.

58% of patients were smokers,52% were consumers of smokeless tobacco, while 37%

were alcoholics. Oral lesion was the most common symptom in our study. Cheek was the

commonest site followed by oral tongue. Squamous cell carcinoma was the commonest

histological variety. Majority of the tumours were well differentiated

CONCLUSION:

Malignancy of oral cavity and oropharynx is predominantly a disease of males. It

usually affects older age group. Manual labourers and people with poor socioeconomic

background are more vulnerable to oral and oropharyngeal malignancy. Tobacco and

alcohol consumption are important etiological factor for oral and oropharyngeal

malignancy.Presence of oral lesion is the commonest symptom. Cheek is the commonest

site involved. Squamous cell carcinoma is the commonest histological variety majority of

them are well differentiated.

KEY WORDS: Malignancy, oral cavity, Oropharynx

TABLE OF CONTENTS

Page No.

1. INTRODUCTION 1

2. AIMS AND OBJECTIVES 2

3. REVIEW OF LITEARTURE 3

4. MATERIALS AND METHODS 27

5. OBSERVATIONS 28

6. DISCUSSION 41

7. SUMMARY 49

8. CONCLUSION 50

9. BIBLIOGRAPHY 51

10. ANNEXURES

PROFORMA

MASTERCHART

LIST OF TABLES

Table

No. Table Page No.

1. Age Distribution 29

2. Occupation 30

3. Literacy 30

4. Socio economic status 30

5. Habits 31

6 Symptoms 32

7 Site of the tumour 32

8 Differentiation 34

LIST OF FIGURES

Fig.

No. Figure Page No.

1. Sex Distribution 28

2. Age Distribution 29

3. Site of the tumour 33

4. Histopathology 34

5. Verrucous lesion of left cheek 35

6. Ulcerative lesion on right lateral border of tongue 35

7. Specimen of wide excision of carcinoma tongue 36

8. Carcinoma of tonsil - Cut surface 36

9. Well differentiated squamous cell carcinoma 37

10. Moderately differentiated squamous cell carcinoma 37

11. Poorly differentiated squamous cell carcinoma 38

12. Basaloid squamous cell carcinoma 38

13. Sarcomatoid squamous cell carcinoma 39

14. Verrucous carcinoma 39

15. Adenoid cystic carcinoma 40

16. Basal cell carcinoma 40

INTRODUCTION

In the developing world, oral cavity is the fourth commonest site of carcinoma

after lung, stomach and liver in males while in females it is the fifth commonest cancer

after cervix, breast, stomach and lung. Oral cancer is one of the most common cancers in

developing countries. In United States, oral cancer represents approximately 13% of all

cancers thereby translating into 30,000 new cases every year. Smokeless tobacco use has

been implicated for the etiology of oral pre-cancerous and cancerous lesions. In the South

Asian region over one-third of 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. Oral cancer is commonest cancer in India accounting for 50-70% of total

cancer mortality. High proportion of cases among males may be due to high prevalence

of tobacco consumption habits among males. Over the years, the incidence of oral

cancers in the population has increased manifold especially among younger generation,

possibly related to rising trend of paan masala and gutkha chewing, smoking, alcohol

consumption in the population. Though it is more common in males, the rate is increasing

in females also.

Cultural differences in the use of tobacco lead to the variation in the geographic

and anatomic incidence of oral and pharyngeal cancers in accordance with dose response

principle.6

The purpose of the study is to determine the distribution of oral cavity and

oropharyngeal malignancies in relation to age, sex, site, histopathological type and

differentiation.

AIMS AND OBJECTIVES

4. To study the histopathological pattern of oral cavity and oropharyngeal

malignancies.

5. To determine the distribution of oral and oropharyngeal malignancies in

relation to age, sex and site.

6. To study the role of tobacco and alcohol in oral cavity and oropharyngeal

malignancies.

REVIEW OF LITERATURE

Patel et al.,1 studied the relationship of oral cancer with age, sex, site distribution

and habits. Of the 504 patients studied, maximum numbers of patients (319) were above

45 years. Males were affected more with a Male: female ratio of 3:1. Anatomically

anterior part of the oral cavity was involved in 61.3% of cases with tongue being the

commonest site. All were squamous cell carcinoma.

In a study done by Mehrotra and colleagues,2 age specific incidence rate and

pathological spectrum of oral cancers was determined. Of the 303 cases, 232 were males

and 71 females, with a male: female ratio 3.27:1. Majority of cases were observed in 50 –

59 years age group. Tongue was the commonest site (129), followed by buccal mucosa

(58). Squamous cell carcinoma was the commonest.

Iype and coworkers3, studied oral cancers among patients under the age of 35

years. Of the 264 patients studied, tongue was the commonest site (136), followed by

buccal mucosa (69). A male: female ratio of 2.3:1 was observed, with a significantly high

male preponderance in buccal mucosa (4.3:1). Squamous cell carcinoma was the

commonest type.

Bhattacharjee et al.,4 studied the prevalence of head and neck cancers in North

East. Of the 1824 cases studied, oropharyngeal carcinoma was commonest comprising

320 cases and oral cavity third commonest with 182 cases. Commonest site involved in

oral cavity was tongue (32.67%). Male: female ratio in oral and oropharyngeal carcinoma

were 2.14:1 and 3.8:1 respectively. Commonest age group affected was between 40 – 69

years. The commonest histological type in oral cavity& oropharynx was squamous cell

carcinoma accounting to 85.12%&97.5% respectively.

Sinha A et al5 studied the cancer morbidity and mortality profile in Jabalpur. They

found Oral cavity is the commonest site of cancer in males over 30 years of age. In males

between 25 and 30 years, carcinoma of oral cavity was the third common malignancy

after reticuloendothelial system and bone. In females oral cavity was the third common

site after cervix and breast.

Ahluwalia et al. 6 studied the spectrum of head and neck malignancies in

Allahabad. Of the 5,386 cases of head and neck malignancies during the year 1975 to

1996, 3028 were oral and oropharyngeal cancers. Male: Female ratio was 4.2:1. Cheek

was the commonest site involved (1241). Majority of cases were seen in 40 to 70 years of

age, peak in the sixth decade. Squamous cell carcinoma was the commonest accounting

for 96% of cases of oral and oropharyngeal malignancies.

Dhar P.K. et al 7 studied 647 cancer patients to identify risk factors for specific

subsites within the oral and oropharyngeal region. Majority of patients had poor oral

hygiene (85.5%) and belonged to 51-60 years of age group (35.7%). Most of the subjects

were agricultural workers (30.3%). Tongue and floor of mouth were the major subsites

(77.2%). Male to female ratio was highest for tonsil (32.3%) but differed marginally for

other subsites. Tobacco and smoking were found as primary risk factors for several

intraoral subsites. Tobacco posed high risk for buccal mucosa and alveolus. Smoking

affected tonsil and floor of mouth. Alcohol posed more risk for buccal mucosa and floor

of mouth.

Richard W. et al 8 studied the role of tobacco smoking, chewing and alcohol

drinking in the risk of oral cancer in Trivandrum, India. The role of tobacco chewing,

smoking and alcohol drinking patterns on the risk of cancer of the oral cavity was

evaluated using a nested case-control design on data from a randomized control trial.

Data from 282 incident oral cancer cases and 1410 matched controls were analyzed using

multivariate conditional logistic regression models. Tobacco chewing was the strongest

risk factor associated with oral cancer. Effects of chewing pan with or without tobacco on

oral cancer risk were elevated for both sexes. Bidi smoking increased the risk of oral

cancer in men. Dose-response relations were observed for the frequency and duration of

chewing and alcohol drinking, as well as in duration of bidi smoking.

Sankaranarayanan R et al 10 studied the Risk factors for cancer of the buccal and

labial mucosa in Kerala, southern India. The investigation was a case control study. The

risk in males of the following habits was investigated: pan (betel)-tobacco chewing, bidi

and cigarette smoking, drinking alcohol, and taking snuff. Only pan-tobacco chewing was

investigated in females as very few indulged in other habits. Among males predisposing

effects were found for pan tobacco chewing, bidi smoking, drinking alcohol, and taking

snuff. As in males, pan tobacco chewing also had a predisposing effect in females.

Duration of use was a better predictor of risk than either daily frequency of use or total

lifetime exposure, both for pan-tobacco chewing (especially if the habit started before age

21 years) and bidi smoking.

ANATOMY OF ORAL CAVITY AND OROPHARYNX:

The oral cavity and oropharynx represents the upper portion of the digestive tract.

I in addition, the oropharynx constitute a portion of the upper respiratory tract.

Oral cavity: The oral cavity can be divided into the following regions

Lip:

Composed of the orbicularis oris muscle with skin on the external surface and

mucous membrane on the internal surface. Transition from skin to mucous membrane of

the oral cavity is the lip vermilion. The blood supply is by way of labial artery, a branch

of the facial artery. The motor nerves are the branches of the Facial nerve. Sensory nerve

to the upper lip is the infra orbital branch of the maxillary nerve, and to the lower lip is

mental nerve.

Floor of Mouth:

U-shaped area bounded by the lower gingiva and the oral tongue. It terminates

posteriorly at the insertion of the anterior tonsillar pillar into the tongue. The paired

sublingual glands lie immediately below the mucous membrane. Mylohyoid muscle

forms the muscular floor for the oral cavity. The submandibular gland rest on the external

surface of the mylohyoid muscle, and it s tongue like process wraps around the posterior

border of the mylohyoid muscle and extends forward on the internal surface of the

mylohyoid.

Oral Tongue (anterior 2/3 )

Defined as the portion of the tongue anterior to the circumvallate papillae.

Circumvallate papillae locate the division between the oral tongue and the base of the

tongue. The arterial supply is mainly by way of paired lingual arteries.

Tongue is a muscular organ covered by oral mucosa. Mucosa of the anterior 2/3

of the tongue is formed into papillae of three types. The most numerous , the filiform

papillae, appear as short “ bristles” macroscopically. Among them are scattered, the small

red globular fungiform papillae. 6 to 14 large circumvallate papillae form a row

immediately anteriorly to the sulcus terminalis and these papillae contain most of the

taste buds.

The body of the tongue consists of a mass of interlacing bundles of skeletal

muscle fibres, which permit an extensive range of tongue movement. Mucous membrane

covering tongue is firmly bound to the underlying muscle by a dense, collagenous lamina

propria, which is continuous with the epimycium of the tongue muscle.

Buccal Mucosa:

Buccal mucosa is the mucous membrane covering the inner surface of the cheeks

and lips ending above and below with the transition to the gingiva. It ends posteriorly at

the retromolar trigone. The parotid duct opens into the buccal mucosa opposite the

second upper molar. The blood supply is a branch of the facial artery.

Gingiva (Alveolar ridge):

The gingiva includes the mucosa covering the mandible or maxilla from the

gingivobuccal gutter to the mobile mucosa.

Hard palate:

A semilunar area located between the upper alveolar ridge and the mucous

membrane covering the palatine process of the maxillary bones.

Retromolar trigone:

A small triangular surface behind the third molar covering the ascending ramus of

the mandible. It is contiguous above with the maxillary tuberosity. Beneath the mucosa of

the retromolar trigone is the tendinous pterigomandibular raphe, which is attached to the

pterigoid hammulus and the posterior mylohyoid ridge of the mandible and serves as the

insertion of the buccinators, orbicularis oris, superior pharyngeal constrictor muscle.

Oropharynx:

Oral cavity is separated by the oropharynx by the anterior pillar of the Fauces

laterally, junction of the hard and soft palate above, and the line of circumvallate papillae

below. The distal limit of the oropharynx is the floor of the Valleculae, which is also the

level of the Hyoid bone.

The subsites of the oropharynx are:

Base of tongue( Posterior 1/3):

Bound anteriorly by the circumvallete papillae, laterally by the glossotonsillar

sulci and posterioly by the epiglottis. The surface of the base of the tongue appears

irregular due to scattered submucosal submucosal lymphoid follicles. Posterior 1/3 of the

tongue has a relatively smooth stratified squamous epithelium., under which lies masses

of lymphoid tissue containing typical lymphoid follicles. This mass of lymphoid tissue is

known as the lingual tonsil.

Vallecula:

Is a strip of mucosa , that is the transition from the base of the tongue to the

epiglottis.

Tonsillar area:

Is a triangular region bounded anteriorly by the anterior pillar and posteriorly by

the posterior tonsillar pillars and inferiorly by the glossotonsillar sulcus and

pharyngoepiglottic fold. The palatine tonsil lies within the triangle.

Soft palate :

Soft palate is a thin, mobile muscle complex separating the nasopharynx from the

oral cavity and oropharynx. Epithelium of the oral side is squamous and the epithelia of

nasopharyngeal side is respiratory. The soft palate is contiguous laterally with the

tonsillar pillars .

Posterior wall of the Oropharynx:

Mucosa covering the constrictor muscles corresponding to the level of hard palate

above and hyoid bone below.

NORMAL HISTOLOGY OF ORAL CAVITY:

The surface epithelium of this region is of stratified squamous type which tends to

be keratinized in the areas subject to considerable friction, such as the hard palate. The

mucosa is supported by dense collagenous tissue, the lamina propria. In highly mobile

area such as the soft palate and floor of the mouth, the lamina propria is connected to the

underlying muscle by loose submucosal supporting tissue. Numerous small accessory

salivary glands of both mucous and serous types are distributed in the submucosa.

EPIDEMIOLOGY AND ETIOPATHOGENESIS OF ORAL AND

OROPHARYNGEAL MALIGNANCIES:

EPIDEMIOLOGY;

Oral cancer is one of the most common cancers in the world, with approximately

2,74,300 new cases and 1,27,500 deaths occurring each year.8 Two-thirds of those cases

occur in developing countries and the majority are over the age of 40 years at the time of

diagnosis. The highest incidence rates have been observed in the Indian sub-continent.

Five-year relative survival for oral cancer patients is approximately 30% in selected

regions of India. 9

ETIOLOGY:

Risk factors associated with carcinoma of oral cavity and oropharynx are,

smoking, high alcohol intake, dental caries, hot spicy foods, leukoplakia, avitaminosis,

betelnut chewing and smokeless tobacco, chronic glossitis, malnutrition, syphilis,

cirrhosis, Plummer Vinson syndrome, lichen planus, chronic hyperplastic candidiasis,

human immunodeficiency virus, Xeroderma pigmentosa, dyskeratosis congenita,

submucosal fibrosis.

Tobacco:

Cigarette smoking is considered to be the major cause of oral cancer. The risk of

developing oral cancer is three times greater for smokers than the general population of

nonsmokers. Mortality rates from oral cancer increase with the number of cigarettes

smoked daily and diminish with the cessation of smoking.

The mixed habit of using chewing tobacco and smoking has been studied in India

and Pakistan where there appears to be a synergistic reaction between chewing and

smoking that increases cancer development risk.

A 1986 report of the US Surgeon General, The Health Consequences of Using

Smokeless Tobacco concluded that the use of smokeless tobacco increases the risk of oral

cancer. Smokeless tobacco users in addition to their cancer risk also may become

addicted to nicotine.

There appears to be link between the extent of tobacco use and development of

oral cancer. A study by Hirayama showed that the risk for developing oral cancer after

using betel quid, a practice particularly prevalent in large populations of south East Asia

and India, more than doubled when the frequency of use rose to six or more times per day

as opposed to twice per day. Similarly Ho has linked the rising trend in oral cancer in

Taiwan to rising consumption of betel quid in that country.

Alcohol:

Its role in the development of oral cancer as a singular agent remains the subject

of continuous investigation. It has been difficult to design research that can determine

how tobacco and alcohol act independently or in synergy to produce oral cancer because

many heavy drinkers are also heavy users of tobacco products in one of its forms. In 1957

Wynder et al. reported that excessive alcohol consumption may be a significant factor in

the development of the cancer of the oral cavity.

Alcohol’s role in the development of cancer in younger age groups is much

debated. While certain studies show a high percentage of their young cancer patients to

be abusers of alcohol and tobacco, others report that inherent genetic determinants play

more of a role in oral cancer development in young patients.

Actinic radiation:

The role of actinic radiation in the development of cancer in the oral cavity relates

most directly to the role sunlight plays a role in producing cancer along the vermilion

border of the lip. The incidence of these ‘sunlight-induced cancers’ is much higher in

fair- skinned individuals who are constantly exposed to the outdoor life.

Nutrition:

Sideropenic dysphagia of patients with Plummer Vinson Syndrome predisposes to

oral cancer. This type of iron deficiency anemia can be seen in oral cancer patients who

are neither alcohol abusers nor tobacco users. Increased mitotic activity tends to diminish

the mitotic activity of the epithelium, promoting mucosal atrophy and enhancing

neoplastic potential.

Recent studies have confirmed the protective role played by certain

micronutrients like vitamins, beta carotins, iron, zinc, magnesium, vegetables, fruits,

cereals and olive oil in preventing the development of oral cancers. McLaughlin et al.

have suggested that carotin and other vitamins may reduce one’s risk for oral and

pharyngeal cancer. Gupta et al. in two epidemiologic studies in India found that lack of

certain nutritional factors are probably contributory to the development of oral mucous

membrane cancer rather than the primary functional etiologic agent and that certain food

groups have a protective role.

Orodental factors:

Poor oral hygiene, improperly fitting dental prostheses, defective dental

restorations and malaligned or sharp teeth are agents that might promote oral and

pharyngeal cancer.

Occupational factors:

Occupational exposure to certain chemicals like formaldehyde, nickel, chromium,

and leather – tanning products has been implicated as factors in the development of oral

cancer.

Viruses and other infectious agents:

The viruses most commonly implicated in oral cancer transformation are Human

Papilloma Virus ( HPV), Herpes Simples Virus ( HSV), and the Adenovirus. Of these

HSV and HPV are most thoroughly studied and are considered to be the most likely

‘Synergistic viruses’ involved in human oral cancer. The herpes viruses that have been

most often linked to oral cancer are the Ebstein Barr Virus (EBV) and the

Cytomegalovirus (CMV).

More than 100 HPV types have been isolated from benign and malignant

neoplasm of oral cavity. HPV antigens and gene products have been detected in biopsies

of oral cancers.

Immune competence:

Compromised immunity related to HIV infection, organ transplantation or

chemotherapy or radiation therapy may act as contributory factors in the development of

oral cancers. Studies also suggest that HIV-16 transfectants play a significant role in oral

cancer development by altering intercellular immune surveillance mechanisms.

Genetic and familial influences:

Genetic defects associated with a number of inherited cancer syndrome have been

linked to the development of oral cancers. Syndromes associated with defective DNA

repair including Xeroderma pigmentosa, Ataxia telengiectasia, Bloom syndrome and

Fancony’s anemia all have an increased rate of second primary malignancies including

oral cancers. Li-Fraumeni syndrome with its significant p53 mutations has a known

association with head and neck cancers and p53 germ line mutations have been reported

in patients with multiple head and neck primary cancers.

CLINICAL PRESENTATIONS OF ORAL AND OROPHARYNGEAL

MALIGNANCIES:

Lip:

Most of lip cancers are seen on the lower lip (85%) much more commonly than

the upper lip (2-7%). There is male predominance with an average age of 60-70 years.

Tumour occurs on the lower lip on the exposed vermilion border just outside the line of

contact with the upper lip, usually halfway between the midline and the commissure.

They present as exophytic, verrucous and ulcerative growth. Exophytic are the most

common and verrucous are rare. The exophytic lesions become necrotic and the

ulceration occurs late, when the tumour is over 1 centimeter. The ulcerative lesions are

minimally elevated and ulceration occurs early. It is usually more aggressive and fixes

the muscle early. Carcinoma of the upper lip and commissure grows more rapidly,

ulcerates sooner and metastasizes earlier than lower lip cancer.

The first lymph nodes to be involved are the submandibular and submental nodes,

with extension into the deep cervical lymph nodes if the lesion is not managed early.

In patients with advanced disease, pain, swelling and tenderness can occur

particularly when infection s present.

Tongue:

Carcinoma of the tongue usually manifest as an ulcerative mass or papillary lesion

in the mid third of the lateral tongue border. Tongue cancer account for 25-50% of all

intraoral carcinoma. More than 70% of tongue cancers occur in the anterior two-thirds of

the tongue, while the posterior third accounts for 25-30%. These tumours are 2-5 times

more common in men than women, with an average age of 60 years. In the anterior

tongue, the lateral border contributes the most common site of occurrence followed by

the ventral aspect, dorsum, and the tip. Tongue cancers can be infiltrative or exophytic.

The infiltrative type may appear to be quite small on the surface, but palpation often

shows that, they have invaded most or part of the tongue.

Buccal mucosa:

Buccal carcinoma affects men more than women, occurs in the older age group.

Most tumours occur in patients between 60 and 70 years of age.11,12 It is common in

India, Africa and South East Asia. In this region the chewing of betel nut and reverse

smoking are common habits. Buccal cancer is often diagnosed at a late stage, as this is

the most insensitive part of the mouth. The most common sites of buccal carcinoma are

the commissure of the moth, along with the occlusal plane and in the retromolar areas.

There are three clinical types of buccal carcinoma- Exophytic, Ulceroinfiltrative

and the Verrucous.

Exophytic carcinomas are found most often around the buccal commissure, where

ulceroinfiltrative carcinomas invade the buccinators muscle early and present a deep

excavating ulcer with diffuse peripheral extension.

The verrucous tumour most commonly occurs on the lower buccal sulcus and the

lower alveolus. It has a characteristic papillary appearance. It may invade the soft tissue

of the cheek, the maxilla and mandible. It rarely metastasizes even to lymph nodes and

almost never to distant sites.

About 15% of buccal carcinomas are associated with palpable lymph nodes at

presentation. But it is said that 5% have microscopic metastasis when there are no

palpable nodes.

Gingiva:

Carcinoma of the Gingiva usually present in the molar and premolar ares. The

vast majority of cases afflicts male patients who are 50 years or older 13 , although recent

trends show an increase among females 14 .

Ulcerations and papillary growths are the most common findings. Because of the

close proximity to bone, there is chance of early invasion into bone.

Floor of the mouth:

Carcinoma of the floor of the mouth is usually identified in the anterior portion of

the mouth beneath the ventral surface of the tongue. Constitute approximately 15% of

oral cancers. 15,16

It may present as a red velvety, wart- like, or ulcerative lesion. Men are affected

two to three times more than women 15,16 . Floor of the mouth cancer tends to affect

mucous membrane anterior to the openings of the submandibular ducts.

Palate:

Carcinoma of the palate is more frequently occurs in soft palate than in the hard

palate. It generally presents as an ulcer or papillary growth 15 . Evans and Shah 17

reported that one third of patients with carcinoma of palate have cervical lymph node

metastasis at the time of diagnosis. In certain parts of India, carcinomas are very common

on the hard palate, owing to the habit of smoking ‘Chuttas’ with the burning end inside

the mouth.

Tonsils:

Tonsillar tumours tend to affect same population of patients as carcinoma

involving other oral cavity sites. However tumours in these areas have a higher rate of

lymph node metastasis 18,19,20 .

PATHOLOGY OF ORAL AND OROPHARYNGEAL MALIGNANCIES:

1) TUMORS OF SURFACE EPITHELIUM (Squamous cell carcinoma and its

variants)

a. Verrucous carcinoma

b. Papillary( exophytic) squamous cell carcinoma

c. Adenoid squamous cell carcinoma

d. Adenosquamous carcinoma

e. Basaloid squamous cell carcinoma

f. Spindle cell (Sarcomatoid) squamous cell carcinoma

g. Small cell carcinoma

h. Lymohoepithelioma like carcinoma

2) TUMORS OF MELANOCYTES

a. Malignant Melanoma

3) TUMORS OF LYMPHOID TISSUE

a. Malignant Lymphoma

b. Plasmacytoma

c. Hodgkin’s Disease

d. Leukemia

4) TUMOURS OF MINOR SALIVARY GLANDS:

a. Adenoid cystic carcinoma

b. Mucoepidermoid carcinoma

c. Adenocarcinoma

SQUAMOUS CELL CARCINOMA:

Grossly, squamous cell carcinoma of the oral cavity can present as an ulcer, an

alteration of mucosal color, or a tumor mass. Ulcerative lesions usually have a

crateriform appearance with rolled elevated borders that are firm because of the

infiltration of tumor along the margins. The cut section usually has a gray-white

glistening appearance.

Microscopically, proliferation of sheets, nests, cords, and neoplastic islands of

epithelium that penetrate into the surrounding connective tissue lamina propria and

submucosa characterize squamous cell carcinoma.

The neoplasm is usually graded histologically as

Grade 1- well differentiated,

Grade2-moderately differentiated,

Grade 3- poorly differentiated,

Grade 4- undifferentiated (nonkeratinizinig) .

The neoplastic cells of well-differentiated squamous cell carcinomas bear a

striking similarity to the cells of normal squamous epithelium. The cells are generally

large with vesicular to oval nuclei and eosinophilic cytoplasm, intracellular bridging is

usually easily discernible, and the degree of nuclear hyperchromatism and bizarre mitotic

activity is minimal. Keratin pearl formation is usually quite prominent in well-

differentiated squamous cell carcinoma, and individual cell keratinization tends to be a

hallmark of this type of the disease. The connective tissue lamina propria and supporting

fibromuscular submucosa into which neoplastic islands penetrate often show a marked

degree of chronic inflammation, predominantly plasma cells and lymphocytes.

In tumors showing moderate degree of differentiation, the tumor cells resemble

normal squamous epithelial cells, hyperchromatism, pleomorphism, anisocytosis and loss

of attachment of cells are more prominent. Frequency of atypical mitosis is increased,

and the frequency of individual cell keratinization and keratin pearl formation is

decreased.

In poorly differentiated carcinomas, there is very little evidence that the tumor is

of squamous origin. Individual cell keratinization is lacking, nuclear:cytoplasmic ratio are

markedly altered; and there is significant pleomorphism and atypical mitoses. Tumor

giant cells may also be seen.

Undifferentiated squamous cell carcinomas, have little if any resemblance to a

neoplasm of squamous epithelium with the cells resembling histiocytes, atypical

lymphocytes, or spindled fibroblasts. Stromal changes may include desmoplastic fibrosis,

vascular hyperplasia and diffuse chronic inflammatory infiltrate.

Squamous cell carcinoma of tongue, lip, buccal mucosa, gingiva, are usually well

differentiated whereas tumors of tonsil are of undifferentiated type.

VARIANTS OF ORAL SQUAMOUS CELL CARCINOMA

a) Verrucous carcinoma:

Grossly, it presents as a papillary or corrugated mass composed of folds of tissue

with finger like clefts between tissue extensions. These papillary folds on cut section are

usually gray white and homogeneous.

Microscopically, there is proliferation of elevated layers of squamous epithelium,

which typically penetrate superficially and broadly into the supporting collagen as

elongated rete pegs .The basement membrane is usually intact, and the epithelium will

often extend as a blunt proliferation into the supporting connective tissue along a

characteristic broad, pushing front as described by Ackerman21. Jacobson and Shear22

indicate that a second characteristic feature of verrucous carcinoma is the manner in

which the normal epithelium at the edge of the lesion is bent on itself by continued

proliferation of the neoplastic epithelium. The supporting collagen typically shows a

dense chronic inflammatory infiltrate. Shafer23 points out that another characteristic

feature is the distinct wedge-like parakeratin plugging between individual finger- like

processes of the neoplasm. Keratohyaline granules, which are seen in verruca vulgaris or

occasionally hyperplastic epithelium, are also rarely seen in verrucus carcinoma.

Verrucous carcinoma must be distinguished from well differentiated squamous

carcinoma. A lesion that shows cytologic atypia, penetration of the growth beyond the

basement membrane, lack of a broad, pushing front of neoplastic growth and no evidence

of parakeratin plugging is a well- differentiated squamous carcinoma.

b) Papillary squamous cell carcinoma:

Is a distinctly uncommon form of squamous cell carcinoma, that usually presents

as a single lesion. These tumours usually de novo, although sometimes they may arise in

the background of existing benign papilloma. 24

Microscopically the lesion is composed of exophytic, thin, short or long finger

like projections with fibrovascular cores. The squamous epithelium shows malignant

features suggestive of an in situ carcinoma and basaloid features and many of the tumours

remain as in situ carcinoma. Surface keratinization is not prominent and is usually absent.

c) Adenoid (Acantholytic) squamous cell carcinoma:

Seen mainly on the lip 22,25,26. Rare cases involving tongue, gingival have also

been reported 27, 28. These lesions usually present as ulcerations or elevated slightly

crusted nodules. Most cases have been reported in men older than 50 years of age 29,30 .

Proposed to be associated with actinic keratosis 29,30. Microscopically the lesions are

characterized by a proliferation of squamous cell carcinoma with central acantholysis and

the development of the cystic spaces filled with desquamated cells, particularly in the

deeper aspect of the tumour. These cystic spaces have pseudoglandular arrangement and

are rimmed by cuboidal epithelium. Typically the stroma shows chronic inflammatory

infiltrate and degeneration of the collagen.

d) Adenosquamous carcinoma:

Gerughty et al. first recognized this tumour in 1968 31. Its a rare, high grade,

aggressive, dimorphic variant that shows both squamous carcinoma and adenocarcinoma

components. The squamous component arises from the surface epithelium in the form of

dysplasia, in situ carcinoma, or invasive squamous carcinoma, while the adenocacinoma

arises from the minor salivary gland ducts in the form of malignant gland formations in

various grades of differentiation.

e) Basaloid squamous cell carcinoma:

First described by Wain and coworkers in 1986 32. This is a rare and aggressive

neoplasm generally arises in the larynx. Intraoral sites include tongue base, floor of the

mouth, buccal mucosa and palate. The mean age has been reported to be 62 years and

most patients with this disease have been smokers 33. Histopathologically the tumour has

two distinct components:(1) a component of well-or moderately differentiated squamous

cell carcinoma, and (2)infiltrating tumor cell nests with smoothy contoured lobules that

may show peripheral palisading and often shows central necrosis (comedo pattern ) and

high mitotic rate. A spindle cell component is sometimes seen. The stroma between the

cell nests can be myxoid or show hyalinosis. The cells have scant cytoplasm with round

to oval hyperchromatic or vesicular nuclei. Tumour is biologically aggressive with early

regional and distant metastasis hence has poor prognosis.

f) Spindle cell squamous cell carcinoma:

Also been referred to as pleomorphic carcinoma, metaplastic carcinoma,

sarcomatoid squamous cell carcinoma, and polypoid squamous cell carcinoma. Common

in men of 6th or 7th decade of life 34,35,36,37. Etiologically this is related to smoking, alcohol

abuse, and prior irradiation 37,38,39. Most frequently identified on the lips, the lower lip is

the most commonly involved oral site. Clinically they present as polypoid, nodular or

fleshy lesions 38. Grossly, the lesions have a smooth, glistening, often whorled pattern on

cut surface. Histologically, the lesion presents as an undifferentiated or anaplastic

proliferation of spindle and stellate cells, often arranged in interlacing fascicles,

resembling a tumour of connective tissue origin. Usually a component of conventional

squamous cell carcinoma is seen.

g) Small cell carcinoma.

It may be pure or associated with a squamous component and its behavioiur is

very aggressive 40. Appearance is similar to homonymous lung carcinoma.

h) Lymphoepithelioma like carcinoma:

Occasionally seen in oral cavity. Tumour is similar to lymphoepithelioma of

nasopharynx and tonsils 41.

MALIGNANT MELANOMA:

Malignant melanoma of oral cavity is rare, accounting for about 1-8% of all

melanomas. 80% oral melanomas occur on the hard palate, alveolar mucosa, or gingiva.

Common in people of Japanese and black African origin 42. Both pigmented and

Amelanotic varieties occur 43. Some of the tumours have desmoplastic features,

especially when occurring on the lower lip. These are often underdiagnosed because of

their scarce cellularity and sometimes less prominent atypia. The diagnosis should be

suspected in the presence of a spindle cell proliferation in the lamina propria with a

fascicular pattern of growth, particularly if accompanied by prominent clusters of

lymphocytes 44.

MALIGNANT LYMPHOMA:

Most commonly occurs in Waldeyers ring, particularly in palatine and lingual

tonsil, but it can also develop in the Gingival area, Buccal mucosa, or palate. Most

patients in their 6th or 7th decades. Clinical presentation is that of a soft, bulky mass

covered by normal or ulcerated mucosa. Microscopically most are of B cell nature and

follicular center cell origin, of large size and with a generally diffuse pattern of

growth45,46.

TNM STAGING OF ORAL AND OROPHARYNGEAL MALIGNANCIES:

PRIMARY TUMOUR (T):

Tx: Primary tumour cannot be assessed

T0: No evidence of primary tumour

Tis: Carcinoma in situ

T1: Tumour 2 cm or less in greatest dimension

T2: Tumour more than 2 cm but not more than 4 cm in greatest dimension

T3: Tumour more than 4 cm in greatest dimension

T4: Lip: Tumour invades adjacent structures, e.g. through cortical bone,

inferior alveolar nerve, floor of mouth, skin of face

Oral cavity and oropharynx: tumour invades adjacent structures e.g. through cortical

bone, into deep muscle of tongue, maxillary sinus, skin, pterygoid muscles, and larynx.

REGIONAL LYMPH NODES (N):

Nx – Regional lymph nodes cannot be assessed

N0– No regional lymph node metastasis

N1– Metastasis to a single ipsilateral lymph node, 3cm or less in greatest

dimension.

N2 – Metastasis in a single ipsilateral lymph node, more than 3cm but not more

than 6cm in greatest dimension, or in multiple ipsilateral lymph nodes none

more than 6cm in greatest dimension, or in bilateral or contralateral lymph

nodes none more than 6cm in greatest dimension.

N2a – Metastasis in a single ipsilateral lymph node more than 3cm but not more

than 6cm in greatest dimension.

N2b – Metastasis in multiple ipsilateral lymph nodes none more than 6cm in

greatest dimension.

N2c – Metastasis in bilateral or contralateral lymph nodes none more than 6cm in

greatest dimension.

N3 – Metastasis in a lymph node more than 6cm in greatest dimension.

DISTANT METASTASIS (M):

Mx – Distant metastasis cannot be assessed

M0 –No distant metastasis

M1–Distant metastasis

STAGE GROUPING :

Stage 0 –Tis N0 M0

Stage I –T1 N0 M0

Stage II –T2 N0 M0

Stage III – T3 N0 M0

T1 N1 M0

T2 N1 M0

T3 N1 M0

Stage IVA- T4 N0 M0

T4 N1 M0

Any T N2 M0

Stage IVB- Any T N3 M0

Stage IVC- Any T Any N M1

MATERIALS AND METHODS

This study was conducted in the Department of Pathology, Father Muller Medical

College Hospital, Kankanadi, Mangalore. Total 100 patients were studied. Patients

having complaint of growth in oral cavity and oropharynx were selected using purposive

sampling technique. Detailed history was recorded in a proforma, regarding age, sex,

presenting complaints, habits of chewing tobacco, pan and gutkha, habit of smoking and

consumption of alcohol. Thorough examination of oral cavity and oropharynx was done

and site of growth was noted. Biopsy was taken from the growth and was transferred to

the bottle containing 10% neutral formalin, processed, embedded in paraffin and 3-4 µ

thick sections were made. They were stained with Haematoxylin and Eosin stain. Special

stains were used as and when required. Histopathological diagnosis regarding type and

differentiation was made.

Data was analyzed by chi-square test.

INCLUSION CRITERIA:

Patients with growth in oral cavity and oropharynx, undergoing biopsy or surgical

treatment at Father Muller Medical College Hospital, Mangalore.

EXCLUSION CRITERIA:

1. Metastatic lesions to the oral cavity and oropharynx from primary malignancy

elsewhere in the body.

2. Recurrence after treatment of primary oral cavity and oropharyngeal malignancy.

OBSERVATIONS

Total 100 patients having complaint of growth in oral cavity and oropharynx were

studied.

Fig 1. : Sex Distribution

In our study majority (77%) of the patients were males. Only 23% were females.

Table 1: Age Distribution

Age group Number Percent

30-39 4 4%

40-49 15 15%

50-59 30 30%

60-69 24 24%

70-79 21 21%

>=80 6 6%

Fig 2: Age Distribution

Mean age was 60. 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.

Table 2: Occupation

Number Percent

Agriculture 44 44%

Household work 20 20%

Labourer 15 15%

Business 13 13%

Office work 8 8%

Majority (44%) of the patients were agriculturists.

Table 3: Literacy

Number Percent

Literate 88 88%

Illiterate 12 12%

In our study 88% of the patients were literates. 12% were illiterates.

Table 4: Socio economic status

Socioeconomic status Number Percent

Upper 8 8%

Upper middle 27 27%

Lower middle 43 43%

Upper lower 16 16%

Lower 6 6%

43% patients were from lower middle socioeconomic status. 27% patients

belonged to upper middle socioeconomic status. 16% were from upper lower and 6%

were from lower socioeconomic status. Only 8% belonged to upper socioeconomic

status.

Table 5: Habits

Habit Number Percent

Smoking 58 58%

Pan/Gutkha 52 52%

Smoking+pan/gutkha 18 18%

Alcohol 37 37%

Alcohol+ tobacco 44 44%

No habits 14 14%

Among 100 patients with oral and oropharyngeal cancer, 58% gave history of

smoking. 52% were consuming smokeless tobacco in the form of pan or gutkha. 18%

were both smoking and chewing tobacco. 37% were consuming alcohol. 44% were using

alcohol as well as tobacco either smoking or chewing. 14% did not have any habits.

Among 23 female patients 15(65.2%) were chewing pan which is the only habit

found in female patients in our study. 8 (34.8%) females were not having any habit.

Table 6: Symptoms

Symptom Number Percent

Oral lesion 71 71%

Oral pain 21 21%

Bleeding 3 3%

Speech difficulty 3 3%

Dysphagia 12 12%

Neck swelling 13 13%

The most common symptom in our study was oral lesion. 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.

Table 7: Site of the tumour

Site Number Percent

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%

RMT 1 1%

One patient had lesion of both lower lip and oral tongue

Fig. 3: Site of the tumour

In our study Buccal mucosa was the commonest site involved (22%) followed by

oral tongue (21%) and base of tongue (10%).

Fig. 4: Histopathology

Squamous cell carcinoma was the commonest 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.

Table 8: Differentiation

Differentiation Number Percent

Well 47 47%

Moderate 42 42%

Poor 5 5%

Majority of the tumours in our study were well differentiated.

Fig. 5: Verrucous lesion of left cheek

Fig. 6: Ulcerative lesion on right lateral border of tongue

Fig. 7 :Specimen of wide excision of carcinoma tongue

Fig. 8: Carcinoma of tonsil - Cut surface

Fig. 9: Well differentiated squamous cell carcinoma

Fig. 10: Moderately differentiated squamous cell carcinoma

Fig. 11: Poorly differentiated squamous cell carcinoma

Fig. 12: Basaloid squamous cell carcinoma

Fig. 13: Sarcomatoid squamous cell carcinoma

Fig. 14 :Verrucous carcinoma

Fig. 15: Adenoid cystic carcinoma

Fig. 16: Basal cell carcinoma

DISCUSSION

SEX DISTRIBUTION:

In our study majority (77%) of the patients were males. Only 23% were females.

In a study by Patel MM et al1 75% of patients were males. Mehrotra Ravi et al2

from Allahabad, India reported a male: female ratio of 3.27:1. Iype EM et al3 from

Trivendrum, Kerala found a higher preponderance in males (70%) compared to females

(30%). Dhar PK et al7, in their study reported that 68.3% of patients were males. . In a

hospital based study by Khandekar SP et al51 61.3% of patients were males. Durazzo MD

et al47 from Brazil reported 31.8% cases were females. Dias et al48 from Portugal reported

a male: female ratio of 4:1. Brandizzi D et al49 from Argentina reported 55% oral

malignancies in males.

Study Male Female

Patel MM et al 75% 25%

Mehrotra Ravi et al 76.57% 23.43%

Iype EM et al 70% 30%

Dhar PK et al 68.3% 31.7%

Khandekar et al 61.3% 38.7%

Durazzo MD et al 68.2% 31.8%

Dias et al 80% 20%

Brandizzi et al 55% 45%

This study 77% 23% This shows a male preponderance of oral and oropharyngeal malignancies. The

fact that oral cancer affects many more men than women may be observed in all of the

studies conducted in India as well as other countries.

However gender is not a risk factor per se in oral and oropharyngeal

malignancies.48The difference 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 are usually not indulged in smoking. This

can also be attributed to more males seeking early medical consultation.2

AGE DISTRIBUTION:

Mean age was 60. Maximum number of patients were in the age range of 50-59

(30%), followed by 60-69 (24%) and 70-79 (21%). Only 4% of patients were less than

40 years of age. The youngest patient in our study was 30 years old.

Patel MM et al1 reported 12.9% of oral and oropharyngeal malignancies below

35 years age, 23.8% between 35 and 45, and 63.3% cases over 45 years of age.

In a study by Mehrotra Ravi et al2, the maximum incidence was in 50-59 years

age range. Iype EM et al3 found 2.8% of oral cancer in young patients below 35 years of

age.Dhar PK et al7 reported maximum incidence ( 35.7%) in the age range of 51-60

years.

In a study by Durazzo MD et al47 , the mean age was 57.4 years. Only 8.6 %

patients were 40 years or less. According to Dias et al48, the average age of

diagnosis of oral malignancy was 62 years, with a standard deviation of 12 years.

Brandizzi D et al49 reported the mean age of oral malignancy to be 62 years, with a range

of 19 to 95 years.

According to Wahid A et al50 in Pakistan, the commonest age group affected in

oral cavity squamous cell carcinoma was 41-50 years (38%), followed by 51-60 years

(34%).

Most of the studies found the maximum incidence of oral and oropharyngeal

malignancies in people over 50 years of age. Hence, screening programs targeted to men

over 50 years, would help in early diagnosis or oral and oropharyngeal malignancy and

therefore increase the treatment outcome.

OCCUPATION:

In our study, 44% of patients were agriculturists. 20% of patients that is majority

of female patients were housekeepers. 15% were manual labourers. 13% were

businessmen and 8% were office workers.

Richard W et al8 found that a larger proportion of cases were manual

labourers(84%).

Balaram et al52 observed that industrial manual workers and farmers were at an

approximately 2 fold increased risk of oral cancer compared with clerical workers.

LITERACY:

In our study, 88% of patients were literates. 12% were illiterates.

Richard W et al8 reported lower education level in patients with oral cancer in

Trivandrum, Kerala.

SOCIO ECONOMIC STATUS54 :

In our study majority of patients belong to lower middle, upper lower or lower

socioeconomic status, which consists of 65% of study group. 27% patients were from

upper middle socioeconomic status. Only 8% belonged to upper socioeconomic status.

Khandekar SP et al51, in an hospital based study reported highest incidence of oral

malignancy in lower middle and upper lower socio economic scale. The lower

socioeconomic status may be a risk factor for poor oral hygiene thereby increasing the

risk of oral and oropharyngeal malignancies. Balaram et al52 have shown similar findings

in their study among cases of oral cancer in southern India.

HABITS:

In our study, out of total 100 patients, 58% patients were smokers. 52% were

consuming smokeless tobacco in the form of pan/ gutkha. 18% were both smoking and

chewing tobacco 37% of patients were consuming alcohol. 44% were using alcohol as

well as tobacco either smoking or chewing. Only 14% did not have any habit.

Smoking and alcohol consumption was seen only in males. None of the females

were smoking or consuming alcohol.

Among 23 female patients 15 (65.2%) were chewing pan which is the only habit

found in female patients in our study. 8 (34.8%) were not having any habit.

In a study by Iype et al3, 56.4% of patients were habituated to either tobacco chewing,

smoking or alcohol.

In the study of Khandekar SP et al51, 71.3% of patients were chewing tobacco.

63.3% were smoking tobacco in the form of cigarettes or bidis.

In the study of Durazzo MD et al47 tobacco smoking was identified in 80.8%

patients. Alcohol consumption history was retrieved in 56.6% patients.

Dias et al48 reported history of tobacco use in 57.8% of patients with oral cancer.

Alcohol consumers were 50% of the total number of cases. 43.8% of the patients were

both alcoholics and smokers.

In the study of Balaram et al52 53% of patients were smokers. Drinkers of

alcoholic beverage s were 32%. Pan chewing habit was found in 59% men and 90% of

women.

SYMPTOMS:

The most common symptom in our study was oral lesion. 71% of the patients

presented with the complaint of an oral lesion.

Durazzo et al47 from Brazil also found oral lesion to be the commonest

presenting symptom in their study (88%).

So, any growth or ulcer in the oral cavity should be looked with high index of

suspicion and should lead to further investigation

SITE OF THE LESION:

In our study Buccal mucosa was the commonest 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 AN1, conducted at Surat, Gujarat, Anterior

2/3 of the tongue was the commonest site (23.02%). Next common was posterior

1/3(19.64%), followed by alveolus, lips and cheeks.

Mehrotra R et al2 in their study found tongue to be the commonest site(42.57%)

followed by cheek in19.14%.

Iype EM et al3 found tongue the commonest site (52%) followed by cheek(26%),

alvelolus (10%), palate(4.5%), lip(2.3%) and floor of mouth(1.9%).

In a study done by Bhattacharjee et al4 oropharyngeal cancer was the commonest

site comprising 15.56% of total body malignancy and oral cavity comprising 8.87%.

Tongue was the commonest site of malignancy in oral cavity accounting for 32.67% of

oral cavity malignancy.

Ahluwalia et al6 from Allahabad found a major share (55.6%) of carcinoma

Cheek among lesions of oral cavity.

According to the study by Richard M et al8, the site distribution of oral

malignancy was, cheek (50.7%), tongue (27%), alveolus(8.9%), palate(7.8%), floor of

mouth(3.4%) and lip(1.8%).

Sankaranarayanan R et al10 found Buccal mucosa to be the commonest site of

malignancy of oral cavity.

Durazzo MD et al47 in their study found 55.6% of patients having cancer of the

tongue and floor of mouth.

Dias GS48 of Portugal found involvement of tongue and its subsites in 43% of

cases, Floor of mouth in 18.9%, palate in 6.9%, alveolus and retromolar trigone in 6.6%.

Brandizzi D et al49 in Argentina found marked prevence of gum carcinoma (29%)

and cheek mucosa carcinoma (28%).

Abdul W et al50 in their study at Abottabad, Pakistan, reported maximum number

of oral cancer in Buccal mucosa(34%). Other sites were Lip(26%), Tongue(21%) and

Gums(19%).

Ahmed F and Islam KM53 from the department of Pathology, Dhaka Medical

College, Bangladesh , found Cheek to be the commonest site, the next being the anterior

2/3 of 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.

HISTOPATHOLOGY OF TUMOUR:

In our study, 92% of 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 al1, all the 504 patients in the study had Squamous cell

arcinoma. Mehrotra and colleagues2 also found squamous cell carcinoma as the

commonest histological variety, comprising of 85.12% of oral and 97.5% of

oropharyngeal malignancies.

In a study by Iype and coworkers3Squamous cell carcinoma was the commonest

type (72%). 3.8% had minor salivary gland tumours , 1.9% had soft tissue sarcomas. 6%

had non specific malignancies.

Bhattacharjee et al4 found commonest histological type in oral cavity&

oropharynx was squamous cell carcinoma accounting to 85.12%&97.5% respectively.

Durazzo MD et al47 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.

Dias et al48 from Portugal found squamous cell carcinoma in 93.9% of cases.

Verrucous carcinoma was found in 0.5%. Whereas 1.3% of cases had lymphoma.

Brandizzi D et al49 from Argentina found squamous cell carcinoma in 91%,

verrucous carcinoma in 7% and carcinoma in situ in 2% of total 274 cases.

Wahid A50 from Pakistan found squamous cell carcinoma in 94% and

adenocarcinoma, acinic cell carcinoma and malignant melanoma in 2% each.

Khandekar et al51 in a hospital based study at Nagpur found squamous cell

carcinoma of carried differentiation in 72.5% cases and Verrucous carcinoma in 27.5%

cases.

DIFFERENTIATION OF TUMOUR:

In our study 47% of tumours were well differentiated. 42% were moderately

differentiated and 5% were poorly differentiated.

In the study by Patel MM1, 60.12% of the tumours were well differentiated.

38.7% were moderately differentiated and 1.18% were poorly differentiated.

Mehrotra R et al2 also observed maximum number of well differentaiated

Squamous cell carcinoma. Iype EM et al found well differentiated squamous cell

carcinoma in 52.6% cases, moderately differentiated in 34.2% and poorly differentiated

in 8.9% of cases.

In the study by Dias GS et al48, majority of the tumours of oral cavity were well

differentiated tumours.

Khandekar SP et al51 found well differentiated squamous cell carcinoma in

33.75%, moderately differentiated in 20% and poorly differentiated in 18.75% cases.

However this statistics excluded verrucus carcinoma which constituted 27.5% cases.

Ahmed F and Islam KM53 from Dhaka, Bangladesh also reported well

differentiated squamous carcinoma was the commonest oral cavity malignancy.

SUMMARY

• We studied 100 cases of malignancy of oral cavity and oropharynx

• Malignancy of oral cavity and oropharynx is more common in males than

females

• Maximum number of cases presented between 50 and 59 years of age. Mean age

at presentation was 60 years. Youngest was 30 year old.

• Majority of patients were agriculturists and manual labourers

• 88% of patients were literates, while 12% were illiterates

• Maximum number of patients were from lower middle socioeconomic status

• 58% of patients were smokers,52% were consumers of smokeless tobacco, while

37% were alcoholics

• Oral lesion was the most common symptom in our study

• Cheek was the commonest site followed by oral tongue

• Squamous cell carcinoma was the commonest histological variety

• Majority of the tumours were well differentiated

CONCLUSIONS

• Malignancy of oral cavity and oropharynx is predominantly a disease of males

• It usually affects older age group. But younger age group are not completely

spared

• Manual labourers and people with poor socioeconomic background are more

vulnerable to oral and oropharyngeal malignancy

• Tobacco and alcohol consumption are important etiological factor for oral and

oropharyngeal malignancy

• Presence of oral lesion is the commonest symptom

• Cheek is the commonest site involved, followed by oral tongue

• Squamous cell carcinoma is the commonest histological variety

• Majority of oral and oropharyngeal malignancy are well differentiated squamous

cell carcinoma

BIBLIOGRAPHY

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PROFORMA

Name: Biopsy no:

Age: IP/OP No:

Sex:

Address:

Occupation:

Income:

Literacy:

Chief complaints:

1) Ulcer in the mouth 6) Loosening of teeth

2) Growth in the mouth 7) Difficulty in speaking

3) Difficulty in swallowing 8) Change of voice

4) Pain while swallowing 9) Swelling in the neck

5) Bleeding from mouth 10) Others

Past history:

Family history:

Personal history: diet

Appetite:

Habits:

Alcohol

Tobacco chewing

Pan

Gutkha

GPE:

Local examination:

Clinical Diagnosis:

Investigations:

Histopathology findings:

Type:

Differentiation:

KEY TO MASTER CHART

SCC - Squamous cell carcinoma

BCC - Basal cell carcinoma

Ca - Carcinoma

RMT - Retro molar trigone

MASTER CHART

Habits Symptoms

Nam

e

Age

Sex

IP/O

P N

o.

Bio

ps.N

o

Occ

upat

ion

Lite

racy

Soci

o -e

cono

mic

St

atus

Die

t

Smok

ing

Alc

ohol

Pan

Gut

kha

Ora

l les

ion

Ora

l pai

n

Ble

edin

g

Spee

ch

diffi

culty

Dys

phag

ia

Nec

k no

de

Site

Type

Diff

eren

tiatn

Narayan Naik 65 M 227208 227208 coolie Illiterate lower Mixed no yes yes no yes no no yes no no Oral Tongue SCC well

Carmine mascrahnes 77 F 228678 228678 Agriculture Illiterate upper lower Mixed no no yes no yes yes no no no no Cheek SCC Well

Varunnie K.A. 84 M 225744 225744 Agriculture Illiterate lower mid Mixed yes yes no no no yes no no yes no vallecula SCC Moderate

Rojina Rodrigues 65 F 225667 225667 Housewife Illiterate lower mid Mixed no no yes no yes yes no no no no Cheek SCC Moderate

Narayani 55 F 225053 225053 Housewife Literate upper mid Mixed no no no no yes no no no yes no Oral tongue & lip SCC Well

Oswald Rodrigues 53 M 224674 224674 Mechanic Literate upper mid Mixed no yes yes no yes no no no no no Base of Tongue SCC Well

Eliamma 70 F 224058 224058 Housewife Illiterate lower mid Mixed no no no no yes no no no no no Oral Tongue SCC Well

Joseph Fernandes 59 M 224080 224080 Retired Clerk Literate upper Mixed yes yes no no no no no no yes no Soft Palate SCC Poor

Aithappa Naik 42 M 223013 223013 Agriculture Literate lower mid Mixed no yes no no yes no no no no no lip SCC Well

Ratnakar Poojary 37 M 222850 222850 Bank Employee Literate upper Mixed yes no no yes yes no no no no no Cheek SCC Moderate

John Francis F. 55 M 221501 221501 Agriculture Literate lower mid Mixed yes yes yes no no yes no no no no Floor of Mouth SCC Moderate

Jose Marie Fernandes 54 M 221380 221380 Shopkeeper Literate upper mid Mixed yes no no no yes yes no yes no no Oral tongue Verrucous Ca Well Christopher Ammana 52 M 230993 230993 Driver Literate upper mid Mixed yes yes no no no no no no no yes tonsil SCC Moderate Moiddin 61 M 231015 231015 Shopkeeper Literate upper mid Mixed yes no yes no no no no no yes yes Vallecula SCC Poor

Francis ferrao 42 M 229779 229779 Shopkeeper Literate upper mid Mixed no no no no yes no no no no no Oral Tongue SCC Well Jagannath 55 M 231807 231807 coolie Literate lower Mixed yes yes no no no no no no no yes Tonsil SCC Moderate Moidin Kunhi 65 M 231474 231474 Retired Clerk Literate upper mid Mixed no no yes no yes no no no no no Cheek SCC Well

Sannu K. 44 M 228968 228968 Agriculture Literate lower mid Mixed no yes no no yes no no no no no Floor of Mouth SCC Moderate

Silvester d'sa 73 M 7039165 7039165 Agriculture Illiterate lower mid Mixed yes no yes no no yes yes no no no Floor of Mouth SCC Moderate

Lancy Serrao 55 M 235828 235828 Agriculture Literate upper mid Mixed yes yes yes no yes no no no no no Floor of Mouth SCC Well

Magdilen Lobo 76 F 236126 236126 Housewife Illiterate lower mid Mixed no no yes no yes no no no no no Hard Palate SCC Well

Shekhar 49 M 7044315 7044315 Agriculture Literate upper mid Veg yes no no no no yes no no no no Soft Palate SCC Moderate

Kumbe 56 F 230432 230432 Housewife Illiterate lower mid Mixed no no yes no yes no no no no yes Cheek SCC Moderate

Ayesha 65 F 7041170 7041170 Housewife Literate lower mid Mixed no no yes no yes no no no no no Cheek SCC Well

Chinkra Bhandary 70 M 4495 4495 Agriculture Illiterate lower mid Mixed yes yes no no yes no no no no no Base Of Tongue SCC Moderate

Joseph D'souza 49 M 7064920 7064920 Agriculture Literate upper mid Mixed yes no no no yes no no no no yes Oral Tongue SCC Well

Monappa 75 M 234360 234360 Agriculture Illiterate lower mid Mixed yes no no no no no no yes no no Base of Tongue SCC Moderate

Babu 55 M 232274 232274 NMPT worker Literate upper mid Mixed yes yes no no yes yes no no no no Base Of Tongue SCC Moderate

Ambu 63 M 232969 232969 Agriculture Literate upper mid Mixed yes no no no no yes no no no no Vallecula SCC Moderate

Gopalakrishna Bhat 65 M 232277 232277 Agriculture Literate uppper mid Veg yes yes no no no no no no no yes Base Of Tongue SCC Moderate

Joy 45 M 239238 239238 Labourer Literate lower mid Mixed yes no no no yes yes no no no no Oral Tongue SCC Well Mohammed 65 M 237994 237994 Agriculture Literate upper mid Mixed yes no yes no yes no no no no no Cheek Verrucous Ca Well

Mariam 75 F 238582 238582 Housewife Illiterate lower mid Mixed no no yes no yes no no no no no Lower Alveolus SCC Well

Bavu Kunhi 52 M 7064153 7064153 Agriculture Literate lower mid Mixed no no yes yes yes yes no no no no Cheek SCC Well

Vijayan 74 M 240374 240374 Agriculture Illiterate upper mid Mixed yes yes no no no no no no yes no Vallecula SCC Moderate

Sharath 30 M 241107 241107 electritian Literate upper mid Mixed no yes yes no yes no no no no no Oral Tongue SCC Well

Bhavani 60 F 242581 242581 Housewife Literate lower mid Mixed no no no no yes no yes no no no Floor of Mouth SCC Poor

Rita D'souza 53 F 242176 242176 Housewife Literate upper lower Mixed no no no no yes no no no no no Oral Tongue SCC Well

Netravati 60 F 241986 241986 Housewife Illiterate upper lower Mixed no no yes no yes no no no no no Cheek Adenoid

cystic

Manjappa 79 M 241107 241107 Agriculture Illiterate upper lower Mixed yes yes no yes no no no no yes no Tonsil SCC Poor

Ibrahim 65 M 240902 240902 business Literate upper mid Mixed no yes yes no yes no no no no no Cheek Verrucous Ca Well

Karichi 70 F 239671 239671 Housewife Illiterate lower mid Mixed no no yes no yes no no no no no Cheek SCC Moderate

Madhavi 55 F 243351 243351 housewife literate lower mid Mixed no no no no yes no no no no no Oral Tongue SCC Well

Elias D'souza 55 M 245368 245368 Agriculture Literate lower mid Mixed no yes no no no no no no yes yes Tonsil SCC Poor

Devaraja 48 M 8009101 8009101 coolie Literate upper lower Mixed yes yes no no no yes no no no no Post Pharyngeal

wall SCC Well

Kunhi Kannan 60 M 8006711 8006711 Fishing Literate lower mid Mixed yes yes no no no yes no no yes no Lat Pharyngeal

wall SCC, basaloid Moderate Indira 60 F 8009142 8009142 coolie Illiterate lower mid Mixed no no no no yes no no no no no Lip BCC -

Joseph Sequera 71 M 8007701 8007701 Agriculture Literate lower mid Mixed no no yes no yes yes no no no no Cheek SCC Well

Lawrence Pinto 65 M 8014963 8014963 Agriculture Literate lower mid Mixed yes no no no no no no no yes no Soft Palate SCC Moderate

Staney Pinto 60 M 246823 246823 Agriculture Illiterate upper lower Mixed yes yes no no no no no no no yes tonsil SCC Moderate

Krishna Bangera 55 M 247727 247727 Shopkeeper Literate upper mid Mixed yes yes no no no no no no no yes Vallecula SCC Well

Satyanarayan Bhandari 78 M 247604 247604 Agriculture Illiterate lower mid Mixed yes yes no no no no no no no yes Base Of Tongue SCC Moderate

Rukmini 77 F 248429 248429 Housewife Illiterate lower Mixed no no no no yes no no no no no Cheek SCC Moderate

Seetu 80 F 249227 249227 Housewife Illiterate lower Mixed no no no no yes yes no no no no Cheek SCC Moderate

Charles D'Costa 68 M 8018970 8018970 Agriculture Literate upper mid Mixed no yes yes no yes yes no no no no Cheek SCC Moderate

Kukra Gauda 68 M 8019297 8019297 Agriculture Literate lower mid Mixed yes yes yes no no no no no yes no Base of Tongue SCC Moderate

Thomas T 64 M 252319 252319 business Literate upper Mixed no no no no yes no no no no no Cheek SCC Well

Govinda Naik 71 M 253659 253659 Agriculture Illiterate lower mid Mixed yes no no no no no no no no yes Tonsil SCC Well

Marcel Pinto 85 M 253679 253679 Agriculture Illiterate upper lower Mixed yes no yes no yes no no no no no Lip SCC Well

Mathias Lobo 71 M 253706 253706 Agriculture Illiterate lower mid Mixed yes no no no no yes no no no no Base Of Tongue SCC Well

Lokamma 70 F 252569 252569 coolie Illiterate lower Mixed no no yes no yes no no no no no Cheek SCC Well Kumar G Uchil 42 M 251189 251189 business Literate upper Mixed yes no no no no no no no no yes Oral tongue SCC Moderate

Narayan Poojary 56 M 254948 254948 Agriculture Literate lower mid Mixed no no no no yes no no no no no Oral Tongue SCC Well

Albert 83 M 8026816 8026816 Agriculture Illiterate upper lower Mixed yes yes yes no yes no no no no no Oral Tongue SCC Well Susheela 55 F 254083 254083 Housewife Literate upper lower Mixed no no yes no yes no no no no no Upper Alveolus SCC Well

Vasanth Nagvikar 42 M 257871 257871 Shopkeeper Literate lower mid Veg yes yes no no yes no no no no no Lip SCC Well

Sankappa Alva 47 M 258128 258128 Agriculture Literate upper mid Mixed no no no no yes no no no no no oral Tongue SCC Well

Jerom Noronha 52 M 258351 258351 Agriculture Literate upper mid Mixed yes no no no no yes no no no no Soft Palate SCC Moderate

Lazarus 78 M 258954 258954 Agriculture Illiterate lower mid Mixed no yes yes no yes no no no no no lip Verrucous Ca Basil Vincent Britto 52 M 260632 260632 business Literate upper Mixed no no no no yes no no no no no oral tongue SCC Well

Sampa Shetty 55 M 260509 260509 Agriculture Literate lower mid Mixed no no no no yes no no no no no oral tongue SCC Well Shankarappa 58 M 262196 262196 Agriculture Literate upper lower Mixed yes yes no no yes no no no no no Hard Palate SCC Moderate

Krishnan 58 M 263485 263485 business Literate upper mid Mixed yes yes no no yes yes no no no no Soft Palate SCC Moderate Abdul Khader 30 M 8046956 8046956 Agriculture Literate lower mid Mixed yes no no no yes no no no no no oral tongue SCC Moderate

Alice D'souza 60 F 268909 268909 Housewife Illiterate upper lower Mixed no no yes no yes no yes no no no oral tongue SCC Well

Poovappa Gowda 58 M 268927 268927 Agriculture Literate lower mid Mixed yes no yes no no yes no no no no RMT SCC Moderate

Ambadi 55 M 268920 268920 Fishing Literate lower mid Mixed yes yes yes no yes no no no no no Floor of Mouth SCC Well

Monappa Poojary 58 M 270622 h/3346/08

270622 h/3346/08 Agriculture Illiterate lower mid Mixed no no yes no yes no no no no no Cheek SCC Moderate

Mohideen 65 M 271050 271050 Agriculture Illiterate lower mid Mixed yes no no no yes no no no no no lip SCC Moderate

Mohan Poojary 70 M 271393 271393 Agriculture Illiterate lower mid Mixed yes no no no yes no no no no no Tonsil SCC Moderate

Abdul Aziz 54 M 271560 271560 Shopkeeper Literate upper mid Mixed yes no no no yes no no no no no Cheek SCC Moderate

Asiya 78 F 272209 272209 Housewife Illiterate upper lower Mixed no no yes no yes no no no no no Upper Alveolus SCC Moderate

Monappa Gatty 78 M 8064900 8064900 coolie Illiterate upper lower Mixed yes no yes no yes no no no no no Lower Alveolus SCC Well

Kushalappa 68 M 271950 271950 Agriculture Illiterate lower mid Mixed yes no yes no yes no no no no no Lower Alveolus SCC Moderate

Cloady Santhoush 40 M 268270 268270 Mechanic Literate upper mid Mixed yes no yes no yes no no no no no oral toungue SCC Well

Singu 55 F 267387 267387 Housewife Illiterate lower mid Mixed no no yes no yes no no no no no Lower Alveolus SCC Well

Shridhar Gambhira 61 M 265949 265949 Agriculture Literate lower mid Mixed yes yes no no no yes no no no no Base of Tongue SCC Well

Krishnappa Bangera 80 M 264976 264976 Retired officer Literate upper Mixed yes yes no no no no no no yes no Base Of Tongue SCC Moderate

Abdul 55 M 8049956 8049956 business Literate upper mid Mixed yes no no no yes no no no no no Hard Palate SCC Moderate

Babu Poojary 60 M 8052006 8052006 retired teacher Literate upper Mixed yes yes no no yes no no no no yes Tonsil SCC Well

Natalia 82 F 8053470 8053470 Housewife Illiterate lower Mixed no no yes no yes no no no no no Cheek SCC Well

Walter Montero 51 M 8057234 8057234 teacher Literate upper Mixed yes no no no yes no no no no no Hard Palate SCC Moderate

Chandra Shekhar 40 M 270206 270206 waiter Literate lower mid Mixed yes yes no no yes no no no no no oral tongue SCC Well

Anand 35 M 2136 2136 Clerk Literate upper mid Mixed yes yes no yes yes no no no no no Cheek SCC Moderate

Naresh 41 M 8063546 8063546 shopkeeper Literate upper mid Mixed yes no no no yes no no no no no oral tongue SCC Moderate

Padmavathi 77 F 274057 274057 Housewife Illiterate upper lower Mixed no no yes no yes no no no no no Cheek SCC well

RameshChand 48 M 286357 286357 Agriculture Literate lower mid Mixed yes no no no yes n no no no no Hard Palate Adenoid

cystic Lowgrade

Nagesh 45 M 276318 276318 waiter Literate upper lower Mixed yes yes no no yes no no no no no Lateral

Pharyngeal wall SCC-basaloid

Krishna 50 M 8067711 8067711 Agriculture Literate lower mid Mixed yes no no no yes no no no no no hard palate Adenoid

cystic

Sheshappa 65 M 21162 21162 Agriculture Illiterate upper lower Mixed yes no no no no no no no yes no Tonsil SCC Moderate