|
 |
|
ORIGINAL ARTICLE |
|
|
|
|
| Year : 2014 | Volume
: 18
| Issue : 2 | Page : 183-188 |
| |
Histopathological correlation of oral squamous cell carcinoma among younger and older patients
Syed Mukith Ur Rahaman1, BR Ahmed Mujib2
1 Division of Oral Pathology and Oral Biology, Ibn Sina National College for Medical Studies, Jeddah, Kingdom of Saudi Arabia
2 Department of Oral Pathology and Microbiology, Bapuji Dental College and Hospital, Davangere, Karnataka, India
| Date of Submission | 11-Oct-2013 |
| Date of Acceptance | 30-Jul-2014 |
| Date of Web Publication | 17-Sep-2014 |
Correspondence Address:
Syed Mukith Ur Rahaman
Head of Division of Oral Pathology and Biology, Ibn Sina National College for Medical Studies, P.O. 31906, Al Mahjar, Jeddah - 21418, Kingdom of Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0973-029X.140734
 Abstract | | |
Background: Oral Squamous Cell Carcinoma (OSCC) is commonly noted in elder men, when occurring in younger individuals, its aggression and prognosis is questioned due to biased data in literature. Traditionally, various histopathological grading systems have been used for assessing aggression and prognosis of OSCC. However, multifactorial grading of Anneroth et al., is considered effective. Materials and Methods: In this retro-prospective study, files of 75 OSCC patients were retrieved from Oral Pathology Department; among this 50 patients were >40 years and 25 patients were ≤40 years of age. Archival formalin fixed paraffin embedded tissue blocks of these patients were used to prepare hematoxylin and eosin (H and E) stained sections for grading OSCC based on Broder's and Anneroth et al., criteria. Further, recurrence of OSCC among study subjects within 5 years of treatment was evaluated. Chi-square test was used to compare the disease in patients who were >40 years with ≤40 years. Results: Comparison according to Broder's classification didn't show any relevant variation. Three of the six parameters and overall grading according to Anneroth et al., criteria showed statistically higher grades of OSCC in the younger age-group; however, there was no significant difference in 5-year recurrence rate. Interpretation and Conclusion: Results of the study are suggestive of aggressive OSCC among young patients when compared to older. Conversely, this aggression didn't affect the recurrence in younger patients. Further studies on genetics, diet and demographics of patients below 40 years of age affected by OSCC will be of greater value.
Keywords: Anneroth et al. grading, multifactorial histopathological grading, oral squamous cell carcinoma, young patients
How to cite this article:
Ur Rahaman SM, Ahmed Mujib B R. Histopathological correlation of oral squamous cell carcinoma among younger and older patients. J Oral Maxillofac Pathol 2014;18:183-8 |
How to cite this URL:
Ur Rahaman SM, Ahmed Mujib B R. Histopathological correlation of oral squamous cell carcinoma among younger and older patients. J Oral Maxillofac Pathol [serial online] 2014 [cited 2022 Aug 20];18:183-8. Available from: https://www.jomfp.in/text.asp?2014/18/2/183/140734 |
| Introduction | |  |
Oral cancer is one of the most familiar forms of cancers in the Indian subcontinent. [1],[2] From the beginning of twentieth-century, frequency of oral cancer is known to be high in India. [3] Histopathologically, over 95% of oral cancers are squamous cell carcinomas. [1],[4] Oral squamous cell carcinoma (OSCC) is more commonly noted in men usually above 40 years of age [5] and only about 0.4 to 3.9% of the patients are affected by OSCC earlier than 40 years. [6]
Controversies exist in literature regarding aggression and prognosis of OSCC among young patients (below 40 years of age). [5] General view is that OSCC among young patients is more aggressive and has worse prognosis. [7],[8],[9] Few studies suggest that 5-year survival rate of patients below 40 years is better than that of patients above 40 years [10],[11],[12] and some other authors state that young patients have a similar clinical course and their survival rate is no different from other age-groups. [13],[14],[15]
Various histopathological grading systems of OSCC have been discussed in literature and Broder's grading has been popular since a long time. [16],[17] Advances in diagnostic technology has led to introduction of multifactorial histopathological grading systems such as Anneroth et al's grading system, which is considered appropriate since it provides valuable diagnostic and predictive information of OSCC. [18],[19] This study attempts to evaluate aggression of OSCC histopathologically by both Broder's and Anneroth et al's., (1987) grading in patients above forty and below forty years of age. Furthermore, an attempt is made to assess the prognosis of OSCC in younger patients by matching 5-year recurrence rate among patients >40 years with ≤40 years age-group.
| Materials and methods | | |
Files of the patients reported with OSCC from 1997 to 2005 were retrieved from the records section of the Department of Oral Pathology of a Dental Institution in India. Only those patients whose archival formalin fixed paraffin embedded specimens were available for further processing were considered for this study. Patients who didn't take treatments, who had other systemic diseases and who were diagnosed with histopathological variants of OSCC were excluded from the study.
Final number of patients in the study was 75 of which 50 patients were >40 years of age were randomly selected to make group-I and 25 patients who were ≤40 years of age were similarly selected to make group-II. More patients in the elder group were used to increase the statistical power for comparison. Archival formalin fixed paraffin embedded tissue blocks of these patients were subjected to soft tissue microtomy for preparation of 5 μm thick tissue specimens. Subsequently they were stained by Hematoxylin and Eosin (H and E) and microscopic examination was carried out for the purpose of histopathological grading based on
- Broder's criteria to classify as well-differentiated squamous-cell carcinoma (WDSCC), moderately differentiated squamous-cell carcinoma (MDSCC) and poorly differentiated squamous-cell carcinoma (PDSCC)
- Anneroth et al., (1987) criteria which include six parameters assessing are as follows:
- Tumor cell population: Degree of keratinization, nuclear polymorphism and mitotic figures [Figure 1], [Figure 2], [Figure 3]
- Tumor-host relation: Pattern of invasion, depth of invasion and lympho-plasmacytic infiltration [Figure 4], [Figure 5], [Figure 6]. Each parameter was graded from 1-4 based on severity. [18] Further, individual patients were given an overall grade using the sum total grades of six parameters and classified into one of the following three grades; grade I: 6-12, grade II: 13-18 and grade III: 19-24. [19],[20]
 | Figure 1: Photomicrograph showing grade 1 keratinization of OSCC according to Anneroth et al., criteria (H&E stain, ×50)
Click here to view |
 | Figure 2: Photomicrograph showing grade 2 nuclear polymorphism of OSCC according to Anneroth et al., criteria (H&E stain, ×400)
Click here to view |
 | Figure 3: Photomicrograph showing grade 2 mitotic figures of OSCC according to Anneroth et al., criteria (H&E stain, ×1000)
Click here to view |
 | Figure 4: Photomicrograph showing grade 1 mode of invasion of OSCC according to Anneroth et al., criteria (H&E stain, ×100)
Click here to view |
 | Figure 5: Photomicrograph showing grade 3 depths of invasion of OSCC according to Anneroth et al., criteria (H&E stain, ×100)
Click here to view |
 | Figure 6: Photomicrograph showing grade 3 Lympho-plasmacytic Infiltrate of OSCC according to Anneroth et al., criteria (H&E stain, ×50)
Click here to view |
Recurrence of OSCC among study subjects within five years of treatment was also evaluated. Recurrent lesions are those, which showed local reappearance of OSCC or cervical lymph node metastasis or distant metastasis after treatment of the initial lesion. Comparison of all the parameters between group-I (>40 years) and group-II (≤40 years) was carried out statistically using Chi-square test.
| Results | | |
Distribution of study subjects according to Broder's classification is shown in [Table 1]; OSCC comparison between the younger and older group of patients didn't demonstrate any relevant difference. According to Anneroth et al.'s six histopathological parameters, three parameters showed significant difference between the age-groups. Consequently, overall grading also showed similar difference. All the parameters which exhibited variations were in higher grades among younger age group ([Table 2], [Table 3], [Table 4]). | Table 2: Distribution of subjects according to Anneroth et al., criteria - tumor cell population
Click here to view |
 | Table 3: Distribution of subjects according to Anneroth et al., criteria tumor host relationship
Click here to view |
 | Table 4: Distribution of study subjects according to overall grade from six parameters
Click here to view |
Total number of patients reported with recurrence in 5 years was 17 out of 75 irrespective of the age-groups. Comparison of 5 years recurrence rate between group-I and group-II didn't appear statistically significant [Table 5] 24% of patients showed recurrence in group-I as against 20% in group-II. | Table 5: Distribution of study subjects according to recurrence in five years
Click here to view |
| Discussion | | |
While oral cancer accounts for only 2% of all malignancies in UK and USA, [21] it is one of the most common cancers in South East Asia, [2] and in India the incidence is as high as one third of all malignancies. [22],[23] About 95% of oral cancers are squamous-cell carcinomas [1],[4] and are commonly seen in elder adults (>40 years). [6] There is a long-standing debate over the aggression and prognosis of OSCC in young patients as compared to older patients and studies have suggested the need for additional research on this topic. [5]
Comparison of OSCC between younger and older age-groups in this study according to Broder's classification didn't show any significant difference. Most of the patients among young age groups were diagnosed with MDSCC (40%) followed by WDSCC (36%) and PDSCC (24%). Reports of similar studies such as Sasaki et al., in UK [5] , Farnaz et al., in Iran, [24] and Iype et al., in India [25] suggest WDSCC as the most common type of OSCC followed by MDSCC and PDSCC. The difference between WDSCC and MDSCC cases in these studies and the present study is only nominal suggesting that the common histopathological type of OSCC is either WDSCC or MDSCC irrespective of age.
Broder's grading of OSCC is a time-honored pathologic tool, [26] but it is slowly expelled from the standard therapeutic planning strategies due to lack of consensus regarding its prognostic value. [27],[28] Hence, grading of OSCC based only on Broder's criteria will be inconsistent and therefore needs to be reconfirmed with other acknowledged systems. There are various advanced grading systems of OSCC proclaiming to be better than Broder's but most of them are done at molecular level and are expensive [29],[30] therefore difficult to adopt in low socioeconomic strata where the incidence of this disease is high. [19] However histopathologic grading that is sensitive and provides valuable diagnostic information that can effectively be applied in the pastoral areas of Indian subcontinent is suggested by Anneroth et al. [18]
In the present study three of the six parameters according to Anneroth et al., criteria showed statistically significant difference between the younger and older groups. Differences in nuclear polymorphism, mitosis index and depth of invasion were more obvious in higher grades among young patients when compared to old patients. A study by Sasaki et al., (2005) [5] used five of the six parameters of Anneroth et al., excluding nuclear polymorphism and found no significant difference between the age-groups.
Furthermore, when the overall grades of Anneroth et al., parameters were evaluated maximum number of patients in study irrespective of age-groups fell under grade 2 (54.66%) followed by grade 1 (40%) and grade 3 (5.33%). Similar trends were reported by Akhter et al., [19] and Doshi et al. [20] Likewise, statistically significant difference in overall Anneroth et al., parameters were also noted with higher grades of disease among the young patients. Studies describe that the histopathological parameters of Anneroth et al., are key indicators of tumor aggressiveness and prognostication since they reflect the relationship of the tumor with the host, [5],[31] based on this our results are reminiscent of greater aggression of OSCC in younger patients when compared to the older.
Five-year recurrence rate irrespective of age in the study was lesser compared to other studies and the number of reported recurrences didn't show much variation between the groups. Pitman et al., (2000) have reported that 45% of their patients showed recurrence in 3 years period with older as well as younger age-groups showing equivalent distribution. [32] Similarly Pytinia et al., (2004) in their study on disease-free survival rates of patients <40 years and >40 years of age have not come across any difference. [33] Conversely, Lacy et al., (2000) have reported higher number of older patients with 5-years recurrence in their study (56% of older patients compare to 35% of younger patients). [34] These results are indicative of either similar or better survival rate for younger patients when compared to older.
| Conclusion | | |
Outcomes of the study are evocative of more aggressive OSCC in younger patients which didn't affect the recurrence rate when compared with older patients. The question that needs to be answered is the actual relationship of aggression and prognosis of OSCC among young individuals when compared with old individuals. Hence, further studies and research on genetics, diet, demographics and tumor host factors will be of a greater value to unveil the reason associated with oral squamous cell carcinoma affecting younger patients.
| Acknowledgements | | |
Mr. Javali, Department of Biostatistics, SDM Dental College, Dharwad. Dr. Keerthi Kumar Rai, Prof and Head, Department of Oral Surgery, Bapuji Dental College, Davangere. Dr. Shabbir Ahmed Sayeed, Head of General requirements, Ibn Sina National College and Hospital, Jeddah, KSA.
| References | | |
| 1. | Moore SR, Johnson NW, Pierce AM, Wilson DF. The epidemiology of mouth cancer: A review of global incidence. Oral Dis 2000;6:65-74. 
|
| 2. | Control of oral cancer in developing countries. A WHO meeting. Bull World Health Organ 1984;62:817-30.
[PUBMED] |
| 3. | Gupta PC, Nandakumar A. Guest editorial: Oral cancer scene in India. Oral Dis 1999;5:1-2.
[PUBMED] |
| 4. | John G Batsakis. The histology of oral cancer. In: Shah JP, Johnson NW, Batsakis JG, editors. Oral cancer. London: Martin Duntiz; 2003.p. 129-64.
|
| 5. | Sasaki T, Moles DR, Imai Y, Speight PM. Clinico-pathological features of squamous cell carcinoma of the oral cavity in patients <40 years of age. J Oral Pathol Med 2005;34:129-33.
|
| 6. | Cuasumano RJ, Persky MS. Squamous cell carcinoma of the oral cavity and oropharynx in young adults. Head Neck Surg 1988;10:229-34.
|
| 7. | Vargas H, Pitman KT, Johnson JT, Galati LT. More aggressive behavior of squamous cell carcinoma of the anterior tongue in young women. Laryngoscope 2000;110:1623-6.
|
| 8. | Sarkaria JN, Harari PM. Oral tongue cancer in young adults less than 40 years of age: Rationale for aggresive therapy. Head Neck 1994;16:107-11.
|
| 9. | Kuriakose M, Sankaranarayan M, Nair MK. Comparison of oral squamous cell carcinoma in younger and older patients in India. Eur J Cancer B Oral Oncol 1992;28:113-20.
|
| 10. | Schantz SP, Yu GP. Head and neck cancer incidence trends in young Americans 1973-1997 with a special analysis for tongue cancer. Arch Otolaryngol Head Neck Surg 2002;128:268-70.
|
| 11. | Yamazaki H, Inoue T, Koizumi M, Yoshida K, Kagawa K, Shimomi H, et al. Age as a prognostic factor for late local recurrence of early tongue cancer treated with brachytherapy. Anticancer Res 1997;17:4709-12.
|
| 12. | Davidson BJ, Root WA, Trock BJ. Age and survival from squamous cell carcinoma of oral tongue. Head Neck 2001;23:273-9.
|
| 13. | Siegelman-Danieli N, Hanlon A, Ridge JA, Padmore R, Fien DA, Langer CJ. Oral tongue cancer in patients less than 45 years old: Institutional experience comparison with older patients. J Clin Oncol 1998;16:745-53.
|
| 14. | Atula S, Greman R, Laippala P, Syrjanen S. Cancer of the tongue in patients younger than 40 years of age. A distinct entity? Arch Otolaryngol Head Neck Surg 1996;16:107-11.
|
| 15. | McGregor AD, Rennie JS. Intra oral squamous cell carcinoma in patients under 40 years of age. A report of 13 cases and review of literature. Br J Plast Surg 1987;40:270-3.
|
| 16. | Rajendran R. Benign and malignant tumors of oral cavity. In: Rajendra R, Shivapathasundaram B, editors. Shafer's Text Book of Oral Pathology. 5 th ed. New Delhi: Reed Elsevier India Private Limited; 2006. p. 143-78.
|
| 17. | The genetic and molecular basis of head and neck cancer. In: Shah JP, Patel SG, editors. Head and Neck Surgery and Oncology. 3 rd ed. London: Mosby Elsevier Limited; 2003. p. 679-93.
|
| 18. | Anneroth G, Batsakis J, Luna M. Review of literature and recommended system of malignancy grading in oral squamous cell carcinomas. Scand J Dent Res 1987;95:229-49.
[PUBMED] |
| 19. | Akhter M, Hossain S, Rahman QB, Molla MR. A study on histological grading of oral squamous cell carcinoma and its co-relationship with regional metastasis. J Oral Maxillofac Pathol 2011;15:168-76.
[PUBMED]  |
| 20. | Doshi NP, Shah SA, Patel KB, Jhabuawala MF. Histological grading of oral cancer: A comparison of different systems and their relation to lymph node metastasis. National Journal of Community Medicine 2011;2:136-42.
|
| 21. | Cawson RA and Odel EW. Oral Cancer. In: Cawson RA, Odel EW, editors. Essentials of Oral Pathology and Oral Medicine. 8 th ed. Philadelphia: Churchill Livingstone; 2008.p. 277-90.
|
| 22. | Henk JM. Malignant Tumors of the Oral Cavity (Management of Malignant Diseases. Series). In: Langdon JD, editor. London: Edward Arnold; 1986. p. 2-8.
|
| 23. | Shankarnarayan R. Oral cancer in India: A clinical and epidemiological review. Oral Surg Oral Med Oral Pathol 1990;69:325-30.
|
| 24. | Falaki F, Dalirsani Z, Pakfetrat A, Falaki A, Saghravanian N, Nosratzehi T, et al. Clinical and histopathological analysis of oral squamous cell carcinoma of young patient in Mashhad, Iran: A retrospective study and review of literatures. Med Oral Patol Oral Cir Bucal 2011;16:e473-7.
|
| 25. | Iype EM, Pandey M, Mathew A, Thomas G, Sebastian P, Nair MK. Oral cancer among patients under the age of 35 years. J Postgrad Med 2001;47:171-6.
[PUBMED] |
| 26. | Langdon JD, Henk JM. Classification and staging. In: Langdon JD, Henk JM. Malignant tumors of the mouth, jaws and salivary glands. 2 nd ed. London: Edward Arnold;1995.p. 36-49.
|
| 27. | Roland NJ, Caslin AW, Nash J, Stell PM. Value of grading squamous cell carcinoma of the head and neck. Head Neck 1992;14:224-9.
|
| 28. | Langdon JD, Patridge M. Expression of the tumor suppression gene p53 in oral cancers. Br J Oral Maxillofac Surg 1992;30:214-20.
|
| 29. | Kearslay JH, Furlong KL, Cooke RA, Waters MJ. An immunohistochemical assessment of cellular proliferation markers in head and neck squamous cell cancers. Br J Cancer 1990;61:821-7.
|
| 30. | Tytor M, Frazen G, Olafsson J. DNA ploidy in oral cavity carcinomas with special reference to prognosis. Head Neck 1989;11:257-63.
|
| 31. | Dantas DD, Ramos CC, Costa AL, Souza LB, Pinto LP. Clinical-pathological parameters in squamous cell carcinoma of the tongue. Braz Dent J 2003;14:22-5.
|
| 32. | Pitman KT, Johnson JT, Wagner RL, Myers EN. Cancer of the tongue in patients less than forty. Head Neck 2000;22:297-302.
|
| 33. | Pytynia KB, Grant JR, Etzel CJ, Roberts D, Wei Q, Sturgis EM. Matched analysis of survival in patients with squamous cell carcinoma of the head and neck diagnosed before and after 40 years of age. Arch Otolaryngol Head Neck Surg 2004;130:869-73.
|
| 34. | Lacy PD, Piccirillo JF, Merritt MG, Zequeire MR. Head and neck squamous cell carcinoma: Better to be young. Otolaryngol Head Neck Surg 2000;122:253-8.
|
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
| This article has been cited by | | 1 |
Are Survival Outcomes Different for Young and Old Patients with Oral and Oropharyngeal Squamous Cell Carcinoma? A Systematic Review and Meta-Analysis |
|
| Swagatika Panda, Neeta Mohanty, Saurav Panda, Lora Mishra, Divya Gopinath, Alkananda Sahoo, Sumanth Kumbargere Nagraj, Barbara Lapinska | | Cancers. 2022; 14(8): 1886 | | [Pubmed] | [DOI] | | | 2 |
IMMUNOHISTOCHEMICAL EXPRESSION OF P53 AND CYCLIN D1 IN SQUAMOUS
CELL CARCINOMAAND EPITHELIAL HYPERPLASIA OF ORAL MUCOSA. |
|
| Anam Singh, Rashmi Arora, Sunil Ranga | | INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH. 2021; : 56 | | [Pubmed] | [DOI] | |
|
|
|
|
