|Year : 2015 | Volume
| Issue : 4 | Page : 605-610
Carcinoma of buccal mucosa: A site specific clinical audit
V Singhania, BV Jayade, V Anehosur, K Gopalkrishnan, N Kumar
Department of Oral and Maxillofacial Surgery, Craniofacial Unit, SDM College of Dental Sciences and Hospital,
Dharwad, Karnataka, India
|Date of Web Publication||10-Mar-2016|
Department of Oral and Maxillofacial Surgery, Craniofacial Unit, SDM College of Dental Sciences and Hospital,
Source of Support: None, Conflict of Interest: None
BACKGROUND: Carcinoma of buccal mucosa is the most common cancer of the oral cavity in India. Treatment of oral cancer poses unique reconstructive challenges, owing to the dynamic architecture of the oral cavity. Despite current progress in various treatment modalities, over the past 50 years survival rates have not improved drastically. Although, philosophy on treatment of buccal mucosa carcinoma remains well-established, due to the relative paucity of reported data, retrospective reviews of institutional experiences are of prime importance. This study provides a detailed insight on this site specific cancer of the oral cavity in the Indian population. AIM: The aim of this study is to analyze our experience with the management of carcinoma of buccal mucosa; associated clinical presentation, outcomes and prognostic factors. SETTINGS AND DESIGN: A retrospective chart review was performed of all cases of primary buccal mucosa carcinoma treated surgically between years 2008 and 2012 in SDM Craniofacial Unit, Karnataka, India. MATERIALS AND METHODS: All cases were analyzed based on patient characteristics, clinical presentation, surgical and adjuvant therapy rendered and treatment outcomes. A retrospective chart review was carried out using the hospital's data base for the same. STATISTICAL ANALYSIS USED: Kaplan-Meier methods were used for analyzing disease free survival (DFS). Univariate analysis of prognostic factors was performed with log rank test. RESULTS: The significant variables in univariate analysis were: Overall stage, T-stage (T1/T2 vs. T3/T4) and nodal status (N0 vs. N+). We found that staging, tumor size and nodal status were significant prognostic factors for DFS. CONCLUSION: The strong influence of overall disease stage, tumor size, nodal status, final histopathological report and habits of tobacco/betel quid chewing, on prognosis; emphasizes the importance of early diagnosis and prevention of carcinoma of buccal mucosa in the Indian population.
Keywords: Buccal mucosa carcinoma, disease free survival, prognostic factors, T-stage, N-stage
|How to cite this article:|
Singhania V, Jayade B V, Anehosur V, Gopalkrishnan K, Kumar N. Carcinoma of buccal mucosa: A site specific clinical audit. Indian J Cancer 2015;52:605-10
| » Introduction|| |
Oral and pharyngeal cancer, grouped together, is the sixth most common cancer in the world. Cancers of the oral cavity are known to be associated with high mortality and morbidity. Although in western countries, the incidence of oral cancers is about 3% of all malignancies, in India, it ranks first 45%.
A significant variation in the site of occurrence of cancer in the oral cavity has been seen which has been attributed to the habit of tobacco consumption in its various forms. Smoking tobacco leads to more involvement of tongue, floor of mouth and hypopharynx due to sump like effects, which is more commonly seen in the western developed countries while, chewable tobacco shows the occurrence of cancer more frequently in the retromolar trigone (RMT) and the buccal mucosa region.
Carcinoma of the buccal mucosa is the most common cancer of the oral cavity in India. Approximately 13,500 cases of carcinoma buccal mucosa have been reported from the various Indian cancer registries during 1990-1996, in comparison to 1272 cases registered world-wide during this 6 year period. The high incidence of carcinoma buccal mucosa in India is probably attributable to smoking and the usage of tobacco in its various forms. Among the 8000 cases reported in Indian hospital based cancer registries during 1994-1998, locally advanced cancers accounted for 70%. The pattern that emerges from the data of hospital based registries over the last 15 years is of a rising trend in the incidence and there is little reason to believe that these numbers will not increase over the next few years. The reported 5 year survival rates for buccal mucosa cancers in India  ranges from 80% for Stage I disease to 5-15% for locally advanced disease., Despite current progress in various treatment modalities, over the past 50 years survival rates have not improved drastically.
These results bring about the need for a detailed insight on this “site specific” oral cancer in the Indian population. Although, the philosophy on treatment of carcinoma of buccal mucosa remains well-established, due to the relative paucity of reported data, retrospective reviews of institutional experiences are of prime importance.
The aim of this study is to analyze our experience with the management of carcinoma of buccal mucosa. We performed a 4 year retrospective review of patients receiving primary treatment at our institution.
| » Material and Methods|| |
A retrospective chart review was performed of all cases of carcinoma of primary buccal mucosa treated surgically between years 2008 and 2012 in Craniofacial Unit, Dharwad, Karnataka.
- Inclusion criteria
- Only patients with histologically confirmed primary squamous cell carcinoma (SCC) of buccal mucosa, including verrucous carcinoma were included
- Only patients that were surgically treated in our unit were included.
- Exclusion criteria
- Non-operable cases and those advised primary palliative care were excluded
- Patients presenting with recurrences of previously treated disease were excluded
- Patients treated with previous chemo/radiotherapy were also excluded.
All cases were staged as per TNM criteria (T- tumor size, N- lymph node involvement, M- distant metastasis) and analyzed based on patient characteristics, clinical presentation, surgical and adjuvant therapy rendered and treatment outcomes. Follow-up data was gathered from medical records and institute's database. The period of follow-up was calculated as duration between the date of surgery to the date of last contact or death of patient. Patient status at the time of last contact was categorized as:
- Dead due to disease;
- Dead due to other causes;
- Disease free survival (DFS alive without disease);
- Alive with disease.
Local recurrence was defined as the discovery of a lesion at the site of, or adjacent to the primary tumor in the oral cavity. Occurrence of positive palpable lymph node in the ipsilateral or contralateral side; post-treatment, was considered as regional recurrence. Recurrence also included cases who presented with distant metastasis. In regard to the site of oral carcinoma, we adhered to TNM classification: AJCC 2002-2003; which recognizes buccal mucosa as that of: (a) Upper and lower lips (C00.3, C00.4); (b) cheek mucosa (C06.0); (c) retromolar region (C06.2); (d) buccal alveolar sulcus, upper and lower vestibule (C06.1).
Kaplan-Meier methods were used for analyzing DFS. Univariate analysis of prognostic factors was performed with the log rank test.
| » Results|| |
The charts and records from craniofacial Unit, Dharwad, identified 71 cases of carcinoma of buccal mucosa from a pathology database of total 133 cases of carcinoma of the oral cavity between January 2008 and April 2012.
The mean age of the patients was 49 years (ranging from 20 to 74 years); the most frequent occurrence seen in the age group of 50-60 years, i.e., 34% (24 patients). There was a significant male pre-dominance with 62 males (87%) and 9 females (13%) reflecting association of high risk factors like tobacco and betel nut chewing being pre-dominantly a male habit [Graph 1]. Furthermore, 99% of the patients admitted to the chronic use of one or more forms of oral tobacco and 90% of them admitted to frequent alcohol consumption.
As for the site of the lesion the involvement was: Buccal mucosa involvement 36% [Figure 1]a; involving oral commissure 3%; involving RMT 6%; involving alveolus 52% [Figure 2]a; involving gingivobuccal sulcus 3% [Graph 2]; the right side involvement 55% (39 patients) was seen to be more than the left side involvement 44% (31 patients) while 1% of the cases saw involvement of bilateral buccal mucosa [Graph 3].
|Figure 1: (a) Case 1 – Pre-operative: Carcinoma of buccal mucosa (b) Case 1 – Intra-operative: Neck dissection and resection (c) Case 1 – Post-operative: Reconstruction with anterolateral thigh flap|
Click here to view
|Figure 2: (a) Case 2 – Pre-operative: Carcinoma buccal mucosa and alveolus (b) Case 2 – Intra-operative: Resection (c) Case 2 – Post-operative: Reconstruction with pectoralis major myocutaneous flap|
Click here to view
Distribution of patients according to tumor stage is given in [Table 1]: the major bulk of the cases presented to us were Stage IV patients 72% (51 patients) while minimum presentation was that of Stage I patients 1% (1 patient).
Neck dissection was carried out in 94% (67 patients) of the cases; modified radical neck dissection: 41% (29), radical neck dissection: 37% (26), and supraomohyoid neck dissection: 17% (12); while no neck dissection was done in 6% (4 patients), which included one case of Stage I and three cases of Stage II [Graph 4].
Bony resections were carried out in 89% (63) of the case s, which was further sub divided as: Hemimandibulectomies 41% (26); marginal mandibulectomies 30% (19); segmental mandibulectomy 13% (8); mandibulectomy with maxillary alveolectomy 13% (8) and isolated maxillary alveolectomy (2) 3% [Graph 5].
Reconstructive options included the use of 40 pedicled flaps [Figure 2]b, [Figure 2]c; 16 free flaps [Figure 1]b, [Figure 1]c and 15 other flaps. (i.e. skin graft and primary closure) [Graph 6] and [Graph 7]. The details of various reconstructive methods with related complications and flap failures have also been analyzed [Table 2]. The final histopathology revealed 93% of lesions as SCC, 6% as verrucous carcinoma and 1% as dysplastic epithelium [Graph 8].
The follow-up period ranged from 2 to 42 months. The 71 patients were divided into three categories: Number of deaths; number alive; lost to follow-up. Out of the 71 patients, 22 patients (31%) were lost to follow-up. Those dead or alive were further categorized as – dead due to disease; dead due to other causes; alive without disease DFS; and alive with disease.
In our study, death was seen in 13 patients (18%) and all deaths were reported to occur within 1 year of getting operated. Dead due to disease included 8 patients and dead due to other causes: Five patients. The database has been illustrated in [Table 3].
Recurrence was found in 13 patients, i.e., 26.5% recurrence rate. Among the 13 patients; 11 showed recurrence within the first 1 year. 92% (12) of cases with recurrence belonged to Stage IV while 8% (1) belonged to Stage III. Out of these 13 patients, 2 patients refused to undergo post-operative radiotherapy while all the rest underwent the complete duration of radiotherapy. Six patients presented with local recurrence, five with regional recurrence and two with distant metastasis. The association of recurrence rate to tumor size, neck status, staging and final histopathology report has been illustrated in the table. We found that among the cases with recurrence: 54% presented with positive lymph nodes, metastatic lymph nodes or pericapsular involvement [Table 4].
|Table 4: Rate of recurrence as per tumor size, nodal status and overall staging|
Click here to view
The overall DFS has been illustrated below. The DFS was statistically analyzed using Kaplan-Meier analysis and univariate analysis using log rank test. The comparisons have been detailed in [Graph 9],[Graph 10],[Graph 11],[Graph 12]. The comparison variables were taken as overall staging, tumor size (T-stage) and neck status (N-stage). Although due to small sample size we could not get a significant P value, our analysis clearly indicated 100% DFS in Stage I and II, 90% in Stage III and a constant drop in DFS in Stage IV, i.e., DFS was 37%. The patients with T1 and T2 disease showed higher DFS (85%) than those with T3 and T4 disease (69%). Nodal status also showed significant role in prognosis. N0 patients showed 100% DFS as compared to patients with lymph node positive (N + patients) where DFS was 69%.
| » Discussion|| |
This retrospective analysis was aimed to focus on a “site specific” carcinoma of the oral cavity highlighting on the patient characteristics, clinical presentation, histopathology, surgical and adjuvant treatment rendered and outcome factors as experienced in our institution.
The genesis of oral squamous cell carcinoma (OSCC) is a complex process involving multiple genetic and epigenetic alterations, which can be affected by various risk factors. Cigarette smoking and alcohol consumption are the most recognized risk factors for OSCC in developed western countries. However, in developing countries like India, tobacco and betel quid chewing contribute to the major risk factor for carcinoma occurrence,, hence the reason for maximum presentation of carcinoma of buccal mucosa in our population.
Our analysis reveals 99% of patients with addiction to chronic tobacco chewing habits available in one or the other form. Nearly 90% of the patients also admitted to frequent alcohol consumption. In the current study, there was a significant male preponderance amongst the subjects, i.e., 87% as compared with 15% of females. This correlates with the study conducted by Pathak  who reported that oral cancer shows a predilection for 75-89% of males in Asian countries, compared with North America, where men account for only 14-55%. This discrepancy in sex ratio correlates with the fact that the prevalence of betel quid chewing is much higher among males than females in India.
Furthermore, in our study maximum carcinoma patients belonged in the age group of 50-60 years. This validates the fact that prolonged contact of the quid with the mucosal site is suggested as an important etiological factor in terms of high incidence at specific sites and high frequency and longer duration of habit amongst older individuals.
The final histopathology results reported maximum lesions as SCC (93%) in our study, the most common malignant neoplasm of the oral cavity. We found that among the cases with recurrence, 54% presented with either positive lymph nodes or metastatic lymph nodes or pericapsular involvement. Thus, our study supports the findings of others; that extra-capsular spread of cervical lymph node metastasis is correlated with poorer prognosis and locoregional recurrence.
In terms of stage of presentation, the majority of patients with buccal carcinoma in our study presented with locally advanced cancer, Stage IV presentation being 72%. As per literature, 70-80% of patients with buccal mucosa cancers were found to be locally advanced at the time of presentation. This can be attributed to poor socio-economic status, lack of community awareness and lack of advanced diagnostic facilities amongst the rural population of our country.
Our overall DFS rate was 74.5% while the recurrence was seen as 26.5% out of which 92% patients belonged to Stage IV and 71% of patients had primary lesion more than 2 cm in size. These results can be correlated with a similar study performed in western India by Iyer. In our study, death was seen in 13 patients out of whom 62% death was due to disease and 100% of these belonged to Stage III and IV. These findings add to the growing body of evidence that advanced stages of oral cancer at the time of diagnosis are associated with shorter survival rates.
In the current study, univariate analysis between staging, tumor size and nodal status with DFS were done using log rank test. We found that staging, tumor size and nodal status were significant prognostic factors for DFS.
The survival rate among our patients in this study declined significantly with advancing stage at diagnosis. In this study, the overall survival rates were higher in patients with Stage I and II disease (100%), as compared with declining survival rates in Stage III (90%) and IV (37%) cases. In terms of tumor size, T1 and T2 tumors showed higher DFS of 85% as compared with T3 and T4 tumors where DFS was 69%. Furthermore, DFS for N0 nodal status was 100%, while for N + was 69%.
Thus, the significant variables in univariate analysis were the overall stage, the T-stage (T1/T2 vs. T3/T4) and the nodal status (N0 vs. N+). When correlated to literature, these findings highlight the importance of screening and early cancer detection and emphasizes on delayed treatment as a poor prognostic factor.
There were some limitations to this study. First, this was a retrospective study, not cohort research; thus, it was sometimes difficult to obtain accurate information during the period of patient follow-up. Second, our data included surgical samples only; hence, we could not analyze the survival rates in those patients referred for primary radiotherapy and chemotherapy. Third, high number of patients who were lost to long-term follow-up was a statistical drawback in our study, hence pointing a strong indication toward improvising a system to encourage long-term follow-up in our country. Thus, further investigations with prospective cohort designs are required to clarify the impact of these prognostic factors on survival in patients with buccal SCC.
Yeole  reported that detecting oral cancer in the early stages, when amenable to single modality therapies, offers the best chance of long-term survival. The results of this study highlighted the importance of oral cancer screening for early detection. Strategies to improve public awareness of oral cancer and continuing education for oral health professionals about early detection and diagnosis must be in place. However, primary preventive measures to curb risk habits associated with oral cancer should be the main agenda to reduce its incidence in view of the low survival rates.
| » Conclusion|| |
Carcinoma of buccal mucosa is a common entity in India due to widespread abuse of oral tobacco products. Most patient present in late stages and require multimodality treatment. The strong influence of overall disease stage, along with tumor size, nodal status, final histopathological report and habits of tobacco and betel quid chewing on prognosis, emphasizes the importance of early diagnosis and prevention of SCC buccal mucosa and aggressive treatment for patients with advanced stage cancer. We would also like to stress on the need for regular follow-up so as to detect and treat complications at the earliest, our overall intent being to provide a better quality-of-life to our patients. Efforts to increase public awareness and effective screening procedures by integration into the basic health-care delivery systems would go a long way toward effectively controlling this most common malignant neoplasm of the oral cavity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| » References|| |
Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncol 2009;45:309-16.
Sargeran K, Murtomaa H, Safavi SM, Vehkalahti MM, Teronen O. Survival after diagnosis of cancer of the oral cavity. Br J Oral Maxillofac Surg 2008;46:187-91.
Babu KG. Oral cancers in India. Semin Oncol 2001;28:169-73.
National Cancer Registry Programme: Consolidated Report of Hospital Based Registries, 1994-1998.
Cancer morbidity and mortality in greater Bombay, 1992-2001.
Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000. Int J Cancer 2001;94:153-6.
Pradhan SA. Surgery for cancer of the buccal mucosa. Semin Surg Oncol 1989;5:318-21.
Iyer SG, Pradhan SA, Pai PS, Patil S. Surgical treatment outcomes of localized squamous carcinoma of buccal mucosa. Head Neck 2004;26:897-902.
Compton CC, Byrd DR. Lip and oral cavity. In: Compton CC, editor. AJCC Cancer Staging Atlas, 2nd
ed. Newyork: Springer Science and Business Media Publishers; 2012. p. 41-53
Ng KH, Siar CH, Ramanathan K, Murugasu P, Chelvanayagam PI. Squamous cell carcinoma of the oral mucosa in Malaysia – Any change? Southeast Asian J Trop Med Public Health 1985;16:602-6.
Chattopadhyay A. Epidemiologic study of oral cancer in eastern India. Indian J Dermatol 1989;34:59-65.
Pathak KA, Nason R, Talole S, Abdoh A, Pai P, Deshpande M, et al
. Cancer of the buccal mucosa: A tale of two continents. Int J Oral Maxillofac Surg 2009;38:146-50.
Singh AD, von Essen CF. Buccal mucosa cancer in South India. Etiologic and clinical aspects. Am J Roentgenol Radium Ther Nucl Med 1966;96:6-14.
Jan JC, Hsu WH, Liu SA, Wong YK, Poon CK, Jiang RS, et al
. Prognostic factors in patients with buccal squamous cell carcinoma: 10-year experience. J Oral Maxillofac Surg 2011;69:396-404.
Indian Council of Medical Research. Guidelines for Management of Buccal Mucosa Cancer, 2010.
Yeole BB, Ramanakumar AV, Sankaraarayanan R. Survival from oral cancer in Mumbai (Bombay), India. Cancer Causes Control 2003;14:945-52.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]