Abstract
57 cases of SCC of jaw who were admitted in Imam Khomeiny and Amir Aalam Hospitals and Institute of Cancer between the years of 1994-1997, were studied. 23 of the cases were female and the rest of them (34) were male. The age range of the patients was 25-85.
21 cases (36.8%) had maxillary involvement while mandible was involves in 37 of the cases (64.9%). In one case (1.7%) both sites were involved (synchronous involvement).
The patients were categorized according to their individual characteristics (sex, age, occupation, birth and place of residence), possible etiologic factors (smoking and family history), complaints, site of involvement, histopathology characteristics of the tumor (stage, grade, and lymphatic involvement), rate of bone and soft tissue involvement, and type of treatment and recurrence of a previous lesion.
According to the results, in spite of late consultation of majority of the patients invasive behavior of the tumor was less than what expected. On the other hand despite of previous radical and invasive treatment performed for the patients, considerable fraction of the cases were the ones who had referred due to recurrence of an original tumor.
Study of birth and living places showed a probable influence of geographical factors in the incidence of the disease.
Key words: Squamous Cell Carcinoma, jaw, Tehran.
Introduction
Malignancies in head and neck area are specifically important considering the anatomic site and the cosmetic aspects for the patients, and also due to subtle position of many of the tumors of this area which causes treatment difficulties (1, 2, 4). From this point of view, orofacial malignancies especially jaw tumors are of great magnitude. The most common malignancy of the jaw is SCC (1-11, 14).
SCC is a epithelial carcinoma (2, 3). It can involve jaw bones in three ways:
The signs and symptoms of these malignancies are Categorizeded according to what Martensson and Larsson's classification (2, 3). The incidence of the signs and symptoms are reported differently in different studies. Different etiologic factors have been reported to be related to the disease including tobacco, aphlatoxin, mustard gas, polycyclic hydrocarbons, and some industrial waste chemicals, and also thorotrast which is used as radio-opaque material in radiology (3-5, 8-10)
Method and material
This was a retrospective, descriptive study using the patients' files. These were patients who were admitted in Imam Khomeiny and Amir Aalam Hospitals and the Institute of Cancer with the diagnosis of SCC of Jaw, between 1994-1997.
The screened files were studied in order to retrieve the information needed for the study, including the individual characteristics of the patients, epidemiologic information, risk factors, some of the anatomic and histopathologic characteristics of the tumors (stage, grade, bone and adjacent tissue involvement and metastasis), clinical manifestations, lab data, treatment and recurrence. The data were then analysed using Epi-Info soft wear.
Findings
A. Individual findings
Form 57 cases, 23 (40.3%) were female and 34 (59.7) were male. The age range of the patients was 25 – 85 years. The mean age was 58.105 years. The most common age was the sixth decade of life (18 cases = 31.6%). More than half of the patients were in the sixth and seventh decades together.
36% of the patients were house wives, 24% farmers, 16% workers, 12% retired, 8% business men, and 4% office workers.
B. Etiology findings
23 patients were asked about smoking, from which 21.74% had a positive history of smoking for 26.7 years in average. Positive family history for the disease was found in 2 patients (3.5). One of them was a 72 years old lady with SCC of the right maxillary bone whose cosine had died from a similar illness, her older sister had expired from bone cancer and her other sister was under chemotherapy for abdominal malignancy. The second patient was a 71 years old lady with left side maxillary bone SCC whose mother had had a similar disease and also her daughter suffered from cervical mass. In 3 of the patients there were positive history of previous or synchronous head and neck malignancy. One of them was a 71 years old female, with SCC of the left maxilla who suffered from Superficial BCC of the left side facial skin at the same time. The other case was a 61 years old woman with SCC of mandible, who had a positive history of adenocarcinoma of tongue 4 months before which was resected. The third case was a 75 years old man suffering from SCC of the right maxilla, with a positive history of right eyelid melanoma 20 years before which was treated by radiotherapy.
C. The site of involvement and clinical presentation
From 57 malignant cases, 21 (36.8%) were in maxillary bone and 37 (64.9%) were in mandible, and in 1 case we had synchronous involvement of the two sites.
Among the patients suffering from maxillary SCC, in 12 cases (57.1%) the disease was only in maxillary sinuses, in 3 cases (14.3%) only the hard palate was involved, 4 patients (9.5%) had both sinus and hard palate involvement, and in 2 cases sinus and alveolar process were involved together. The maxillary sinus was involved in 85.7% (18 cases), hard palate in 33.3% (7 cases), and alveolar process in 9.5% (2 cases). In 10 patients (55.6%) right maxilla and in 8 (44.4%) cases left maxilla was involved. In 3 cases the side of involvement wasn't mentioned.
The female frequency of maxillary involvement was 38.1% (8 cases) and of men was 61.9% (13 cases). Male to female ratio was 1.625. The average age in this group was 61.57 years. The most common clinical presentation was oral symptoms (38.9%) and the next common symptoms were facial ones (36.1%) (Table 1). In average there was a period of 9.83 months between appearing of the symptoms and diagnosis.
Table 1: The frequency of clinical complaints of the patients with SCC of maxilla, admitted in three hospitals in Tehran, 1994-1997.
|
complaint |
As chief complaint |
As one of the complaints |
|
Oral |
10 (52.6%) |
14 (38.99%) |
|
Nasal |
2 (10.5%) |
4 (11.1%) |
|
Orbital |
1 (5.3%) |
2 (5.6%) |
|
Facial |
6 (31.6%) |
13 (36.1%) |
|
Neural |
0 |
3 (8.3%) |
From the patients with Mandibular SCC in 27 cases (72.9%) only the body of mandible was involved, in 4 cases (10.8%) only ramus of mandible, in 3 cases (8.1%) ramus and body, and in 2 cases (5.4%) body and symphysis process of mandible were involved. In general body was involved in 81% (30 cases), and ramus and symphysis in 13.5% (5 cases) each were involved. The side of involvement was right side in 20 cases (57.1%) and left side in 15 cases (42.9%) and in 2 cases there was involvement of both sides.
The female frequency of disease in Mandibular SCC was 40.5% (15 cases) and of men it was 59.5% (22 cases). Male to female ratio was 1.467. The average of age in this group was 57.3 years.
The most common clinical complaint in this group of patients was facial complaints (48.4%) and the next common complaint was oral complaint (35.5%) (Table 2). In average there was a period of 7.33 months between the start of the symptoms and the diagnosis of the malignancy.
Table 2: The complaints that the patients with Mandibular SCC presented with, in three hospitals in Tehran, 1994-1997
|
complaint |
As a chief complaint |
As one of the complaints |
|
Oral |
13 (38.2%) |
22 (35.5%) |
|
Facial |
19 (55.9%) |
30 (48.4%) |
|
Referred pain |
0 |
2 (3.2%) |
|
others |
2 (5.9%) |
8 (12.9%) |
D. Histopathology findings
In terms of grading (histological differentiated), most of the tumors (53.1%) either in maxilla or mandible, were well differentiated (Table 3)
Table 3: Grading of maxillary and Mandibular tumors in patients with SCC of jaw admitted in three hospitals in Tehran, 1994-1997.
|
Grade Site |
Well differentiated |
Moderately differentiated |
Poorly differentiated |
|
Maxilla |
8 (47.1) |
5 (29.4%) |
4 (23.5%) |
|
Mandible |
18 (54.5%) |
11 (33.3%) |
4 (12.2%) |
|
Total |
26 (53.1%) |
15 (30.6%) |
8 (16.3%) |
In 24 of the patients files there was a point made regarding a touchable mass (lymphadenopathy), from which 15 cases (62.5%) were positive for lymphadenopathy. 50% of the lymphadenopathy was found in right side and 50% in left side of head and neck and 1 patient had both sided lymphadenopathy. In 80% of the patients (12 cases) cervical lymphadenopathy was detected, in 26.6% (4 cases) submandibular lymphadenopathy and in 6.6% (1 case) submental lymphadenopathy (Table 4). 14 patients had a certain size for the lymph node mass from which 10 cases (71.4%) were from 1-2 cm, 2 cases (14.3%) 2-3 cm, and more than 3 cm or less than 1 cm were in 1 patient each. The average size of the lymph node was 1-2 cm with standard deviation of 0.699.
Table 4: The distribution of the involvement of lymph nodes according to the side of involvement, in patients with SCC of jaw, admitted in three hospitals in Tehran, 1994-1997.
|
Site of side LAP of LAP |
Cervical |
submandibular |
submental |
Cervical & Submandibular |
Total |
|
Right |
5 (31.25%) |
2 (12.5%) |
1 (6.25%) |
0 |
8 (50%) |
|
Left |
5 (31.25) |
1.(6.25%) |
0 |
2 (12.5%) |
8 (50%) |
|
Total |
10 (62.5%) |
3 (18.75%) |
1 (6.25%) |
2 (12.5%) |
16 (100%) |
LAP= Lymphadenopathy
The size of the tumor in average was 2-3 cm and more than 3/4 of them (76.5%) were 1 - 4 cm (Table 5).
Table 5: Frequency of the size of the tumor in patients admitted in three hospitals in Tehran with SCC of jaw, 1994-1997.
|
Size (cm) |
0-1 |
1-2 |
2-3 |
3-4 |
4-5 |
5-6 |
>6 |
Total |
|
Frequency |
1 (2.9%) |
10 (29.4%) |
8 (23.6%) |
8 (23.6%) |
5 (14.7%) |
1 (2.9%) |
1 (2.9%) |
34 (100%) |
According to TNM tumor staging system, 73.3% of the tumors were T2 or T3 (Table 6). 3/4 of the patients were at S2 or S3 (Stage), at the time of diagnosis (Table 7).
Table 6: T frequency in patients with SCC of jaw admitted in three hospitals in Tehran, 1994-1997.
|
T |
TIS |
T1 |
T2 |
T3 |
T4 |
Total |
|
frequency |
1 (2.2%) |
8 (17.8%) |
20 (44.4%) |
13 (28.9%) |
3 (6.7%) |
45 (100%) |
Table 7: The frequency of stages according to the site of involvement in patients admitted in three hospitals in Tehran with the diagnosis of SCC of jaw, 1994-1997.
|
Stage Site |
S0 |
S1 |
S2 |
S3 |
S4 |
Total |
|
Maxilla |
1 (5.6%) |
0 |
6 (33.3%) |
8 (44.4%) |
3 (16.7%) |
18 |
|
Mandible |
0 |
4 (14.8%) |
10 (37%) |
10 (37%) |
3 (11.2%) |
27 |
|
Total |
1 (0.02%) |
4 (0.08%) |
16 (35.6%) |
18 (40%) |
6 (0.13.3%) |
45 (100%) |
E. Bone and Soft tissue involvement
Among 43 patients with certain information about bone invasion, in 42 cases (97.7%) there was bone invasion including 31 cases (72.1%) of partial bone involvement (from periosteoum to cortex of the bone) and 11 cases (25.6%) of complete bone involvement.
In 37(61.4%) out of 57 cases of SCC of jaw, several types of soft tissue involvement were reported in pathology result in addition to bone involvement. In 13 cases gum was involved (22.8%); involvement of salivary glands, tongue, soft tissues and mouth floor mucosa were in 4 cases each (7%); skin was involved in 3 cases (5.3%); involvement of lips, tonsils and buccal mucosa were in 2 cases each (3.5%); and cervical muscles, soft palate and hard palate mucosa were involved in 1 case each (1.8%).
F. Treatment
In 48 cases (84.2%) surgical operation was performed; chemotherapy was used in 5 cases (8.8%) and radiotherapy in 4 cases (7%). So the most common treatment method was surgery only which was in 43 patients (75.4%).
G. Recurrence
15 patients (26.3%) were recurrence cases of previous lesions from which 12 cases (80%) the illness was in mandible, 2 cases (13.3%) in maxilla and 1case (6.7%) in both bones. 11 cases (73.3%) of these patients were men and 4 cases (26.7%) were women. The gap between the previous illness and the present one was 1-10 years with an average of 3.69. The average of time gap between the previous tumor and the recurrence in the case of Mandibular lesions was 3 years and for maxillary lesions it was 3.8 years.
Discussion and results
I. In this study the relative frequency of the incidence of the illness in men was 1.48 times more than women. Male involvement predominance in malignancy of maxillary sinuses and primary malignancy of oral cavity with extension to jaw is confirmed by other researches and references (14-17). However it is said that in case of primary SCC of the bone it is female predominant with the ratio of 1.5/1.
II. All the patients in this study were adults. The age average was 58 (s.d = 3.64). The peak of the incidence of the disease occurred in the 6th decade. Other references have confirmed this as 6th to 7th decades (1-16).
III. The most common occupation among the patients was working as a house wife, all of these were females. Sex factor is a disturbing factor in analyzing this. The second most common occupation was farming (24%). In addition many of house wives worked in the farm as well. It seems that occupation could be somehow related to the occurrence of the disease.
IV. Less than 1/4 of the patients of this study were tobacco smokers, however the role of tobacco smoking as a predisposing factor for the disease has been proved and established according to other references (5, 6, 6). Positive family history of malignancy was there in 3.5% of the patients; history of a previous or synchronous malignancy in the same patient was positive in 5.3% of the patients; and 80% of these cases were women. In view of these findings it can be concluded that genetic hasn't got an important role, if any, in occurrence of the disease, anyhow considering kind of history was found more in women than men this might worth more study.
V. The majority of jaw involvement was in mandible (77%). According to other references the majority of primary SCC of jaw bones is in mandible which is the same as our results. On the other hand when the malignancy originates from oral cavity which in turn involves the jaw bones, maxillary and Mandibular involvement rates differ depending on the site of the primary lesion. Buccal mucosal SCC especially from verrucous mucosa involves mandible more than maxilla. SCC of oral cavity floor and gum also prefers to involve mandible. On the other hand if hard palate is the original site of the cancer, maxillary bone is more involved than mandible (2, 8).
VI. The most common clinical presentation of the patients with SCC of maxilla, according to this study was oral symptoms (38.9%) and the next common symptoms were facial ones. The patients had referred to the hospital about 9.8 months after the beginning of the symptoms. This is different from other study results in which the most common complaint is reported to be nasal symptoms and the average period that the patients refer to the doctor after the start of the problem is 5 months (2, 11). In the case of Mandibular involvement our results were matching with the other studies, i.e. the most common symptoms was facial complaints and then oral ones and the patients consulted the physician after 7.3 months of the beginning of the illness (1, 2, 4-10).
VII. It is confirmed in our study that in majority of cases of SCC of jaw, including the primary bone malignancy, or sinus or oral malignancy with bone extension, the tumor is well differentiated histologically. This is the same as other studies (2, 5).
VIII. According to text books the majority of these malignancies (about 75%) are T3 or T4 at the time of first referral (2, 5, 8) whereas in our study 73.3% of the cases were T2 and T3 and also 75% of the cases were in Stages 2 or 3 (S2, S3). Bearing in mind the longer period between the beginning of the symptoms and consulting the doctor in our cases comparing to the findings of other studies, we should expect higher stages of the disease at the time of diagnosis. Therefore having the reverse result in this aspect is significant and considerable. It could be probably explained by the fact that the majority of the malignant lesions are moderately to well differentiated.
IX. The best treatment strategy for these malignancy is surgical operation. Combination therapy is recommended strongly so that a combination of surgery and radiotherapy has been considered as the most accepted method in last few years (5, 11). In our study surgery was used for the majority of the patients and depending on the case radiotherapy and chemotherapy was also performed.
X. More than 1/4 of the patients had referred by the chief complaint of the recurrence of a previous tumor; whilst comparing to the other malignancies of jaw and face there is less stress on the frequency of recurrence in SCC (5, 12).
References
Published in: The Journal of Faculty of Medicine, 56th year, no. 5, 1999.
By: H. Borgheie, M.D., E. Razmpa, M.D., F. Tabloei, M.D.