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Issue Year : 2006, Issue Number : 3, Issue Month : September
Written By : Shahid Jamal, *Nadira Mamoon, *Sajid Mushtaq, **Muhammad Luqman
Belongs To : Army Medical College Rawalpindi, *AFIP Rawalpindi, **Foundation University Medical College Rawalpind
1. Hay RJ, Adriaans BM. Bacterial infections. In: Burn T, Breathnach S, Cox N, Griffith C, eds., Rook’s Textbook of Dermatology. Oxford: Blackwell Science Ltd 2004; 7: 27.1-27.85.
Abstract
Objective: To determine the pattern of oral cancer in northern Pakistan.
Design: A descriptive study.
Materials and Methods: All histologically diagnosed malignant tumours of oral cavity excluding salivary gland tumours were retrieved from the case files. Basic epidemiological data regarding each case was collected from the request forms. The data was then analysed for the site of involvement, age distribution and histological types of tumours.
Results: During the study period a total of 723 patients had oral malignancies, constituting 3.4% of all malignant tumours diagnosed during this period. Males and females were almost equally affected (M:F ratio 1.09:1). Peak incidence was in 6th to 7th decades. Ten cases in paediatric age group were also found. Tumours of the tongue were most frequent (27.52%), followed by lips (16.18%), palate (8.16%) and gums & cheek (7.46% and 3.74% each). The Histological pattern was predictable. Statistical analysis showed that there was significantly increased (P<0.001) registration of oral malignancies as compared to our previous analysis.
Conclusion: Oral cancer is included in the first ten common tumours and its registration is increasing in our tumour registry. Tongue and lips are involved in about half of the cases and both genders are almost equally affected. Peak incidence is in 6th to 7th decade and histological pattern is predictable.
Article
INTRODUCTION
The incidence of oral cancer is different in different geographical areas. A high incidence is observed in the Indian subcontinent, Australia, France, Brazil and South Africa. It is 11th most common cancer in the world and two-thirds of new cases are seen in the developing countries [1,2]. Male to female ratio is also variable. In Pakistan also varying reports are found. In the Southern part of the country oral cancer is more frequent than in the North [3-5], but in a study from Peshawar, Pakistan, oral cancer was found to be 3rd common in a combined analysis of Afghan refuges and local population [6]. Smoking and drinking are the major risk factor in developed countries [1]. In the Indian subcontinent, chewing tobacco in the form of betel quid and bidi (hand-rolled tobacco cigarette) are thought to be a major risk factor [4,5,7]. In most of the studies it is reported that tongue and floor of the mouth is involved in majority of the cases followed by lips [8,9] and histologically it is squamous cell carcinoma which is most frequent. The purpose of this analysis is to find out the pattern of oral malignancies in our set up and to compare it with other national and international studies.   

Correspondence: Col Shahid Jamal, Classified Pathologist, Army Medical College, Rawalpindi.
MATERIALS & METHODS

Armed Forces Institute of Pathology, Rawalpindi receives specimens from various military and civil Institutions all over northern Pakistan. All histologically diagnosed malignant oral tumours are registered with AFIP tumour registry. Basic epidemiological data regarding each case was collected from the request forms, which were retrieved from the registry data. The study includes all malignant tumour of oral cavity less tumours of salivary glands, diagnosed from January 1992 to December 2001. The specimens were received in 10% formal saline. Gross examination of surgical specimens was performed and recorded on a proforma. Adequate representative tissue sections from the lesions were taken as described by Rosai [10]. The material was processed under standardized conditions for paraffin embedding. The sections were stained with haematoxylin and eosin (H&E). Special stains were used where, and when required. Each tumour was assigned ICD-O code [11], published by International Agency for Research on cancer (IARC). Chi-Square test was used for statistical analysis and p-value was calculated against observed frequency and expected frequency of different parameters, after adjusting the annual growth rate and increase in population. 
RESULTS
During the study period 723 cases of malignancies from oral cavity were registered, constituting, 3.4% of all malignant tumours diagnosed during the same period. Males were 378 and 345 were females (Male: Female ratio 1.10:1). Age distribution is shown in the figure. Peak incidence was in 60-70 years of age and majority of the cases 347(48%) were seen between 50-70 years age groups. The table shows distribution of the tumours according to the site of involvement.
Tongue (ICD 01.9-02.9) was involved in 199(27.5%) cases, involving both sexes equally. The peak incidence was in 50-60 years age group. Histologically, squamous cell carcinoma was the main type, in 701(97%) cases.
Carcinoma of the lips (ICD 00.0 to 00.9) was seen in 117(16.18%) patients. Lower lip was involved more frequently 86%, as compared to upper lip (14%). Male to female ratio was 1.17:1. Highest incidence was in 6th decade. Squamous cell carcinoma was the predominant lesion.
These two main sites were followed by lesions of palate, gums and cheek (ICD 03.0 to 06.2). Males were more frequently affected (table) and histologically, squamous cell carcinoma was the main lesion. Ten (1.4%) cases of malignancies in paediatric age group (<14 years) were also found. These were mainly cases of lymphoma and soft tissue sarcomas.
Comparison with the previous analysis of same set up for any increased registration of oral cancer was also done. After adjusting the increase in population and population growth rate, it was found that there was significant increased registration for these tumours (P<0.001).
DISCUSSION
The geographical pattern and trends in the incidence of the oral cancer are variable all over the world. A high incidence is found in the Indian subcontinent, Australia, France, South America (Brazil) and South Africa. It is 11th most common cancer in the world and two-thirds of new cases are seen in the developing countries and these cancers are responsible for 200,000 deaths each year world wide [1,2]. The results from the studies in Pakistan also show variable reports. It is reported to be 2nd most frequent in a study from Karachi and 3rd most frequent from a study of Peshawar [4,6], but the study of Peshawar included Afghan refuges as well. We, in this analysis and also in the previous analyses of institute as well, have not found oral cancer to be included in the first five common tumours but is included in the ten commonest [3,12]. Male predominance is not only reported in most of the international studies [1,2,13], but also in majority of the studies from Pakistan [4,6,7,14-16], except in an analysis from Lahore where it was found that females were more frequently affected [17]. We also found males to be slightly more frequently involved than females. Oral cancer is said to be a disease of old age. We found the peak incidence in 6th to 7th decade and same is reported in most of the studies [7,14,16].

The main risk factors, namely the tobacco smoking and alcohol consumption, are well known [1,2] and may be avoided. In addition, the disease may be primarily preventable through avoidance of these risk factors. The oral malignancies can also be diagnosed at early stages with no major difficulties and thus so making these tumors also suitable to secondary prevention. In fact, the oral cavity may be easily examined by health care professionals such as doctors, dentists and nurses. In spite of the relative ease the examination of oral cavity have not been routinely and widely employed and have received little attention from both professionals and patients. As a result, advanced cancer predominates in this region, so these patients have very late diagnosis of their malignancy and patients report on 2nd or 3rd presentation to the proper specialists [2,18].

Other than the major risk factors like smoking and drinking, chewing tobacco in the form of betel quid (combination of betel leaf, slaked lime, areca-nut, and tobacco with condiments) and naswar are the major causative factors in India and Pakistan [5,7,17], Poor oral hygiene and denture sores along with these factors may have additive effects [19]. Association of betel nuts chewing with oral cancer has also been reported in studies from Taiwan [20,21] and in a case control study from Pakistan, high risk for oral cancer was also reported by use of betel quid without tobacco [22]. In a study at Lahore, by Ali et al [17], Hoka and cigarette smoking was found to be more frequently involved in oral cancer as compared to pan, naswar and tobacco chewing. It appears that different aetiological factors are operating in different regions of Pakistan, like chewing tobacco
Table:     Distribution of oral cancer cases (n=723).
 
Site
Male
Female
Total
Percentage
Lip
63
54
117
16.18
Tongue
102
97
199
27.52
Palate
39
20
59
8.16
Gum
25
29
54
7.47
Cheek
17
10
27
3.73
Mouth NOS*
132
135
267
36.93
 
NOS* Not otherwise specified
 
 
Figure: Age distribution of oral cancer cases.
and smoking in Karachi [4,5,7,22], tobacco in the form of naswar in NWFP and Hoka and cigarette smoking in central Punjab [17].
Most of the oral cancers are squamous cell carcinoma (SCC) of different degree of differentiation and variants of squamous cell carcinomas like verrucous carcinoma, sarcomatoid SCC and lymphoepithelioma1 [14,15,23], same was our observation and we found more than 90% patients having squamous cell carcinoma. 
CONCLUSION
In the end we can conclude, that in spite of the fact, this is pathology based tumour registry data analysis with all the biases inherited to such analysis, the study points out that oral malignancies show variable geographical distribution in Pakistan and squamous cell carcinoma of the tongue followed by the lips are the most frequent. Efforts are required for prevention, early detection and to find out causative agents by case control studies, so that many of the quarries which are unanswered can be clarified.
Reference
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