Journal of Orofacial Sciences

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 8  |  Issue : 2  |  Page : 80--85

Oral and maxillofacial malignancies: An analysis of 77 cases seen at an academic medical hospital


Adebayo Aremu Ibikunle, Abdurrazaq Olanrewaju Taiwo, Ramat Oyebunmi Braimah 
 Department of Surgery, Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Usmanu Danfodiyo University, Sokoto, Nigeria

Correspondence Address:
Adebayo Aremu Ibikunle
Department of Surgery, Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Usmanu Danfodiyo University, PMB 12003, Sokoto
Nigeria

Abstract

Introduction: Oral and maxillofacial malignancies (OMMs) consist of a wide range of lesions, which constitute varying proportions of the total incidence of malignancies in the human population. Available epidemiological data vary across racial, geographical, gender, and occupational divides. They are often associated with significant impairment of patients' quality of life. Materials and Methods: A review of hospital records of patients with histologically diagnosed primary OMM, who presented to the Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, over a 5-year period, was done. Data including age, gender, site, and type of tumor, and histological grade of tumor were retrieved and analyzed with the SPSS version 20.0. Results: A total of 77 cases of OMMs were identified with a male/female ratio of 1:1.03. The mean (±standard deviation) age was 50.1 (17.8) years. Squamous cell carcinoma was the most frequently seen epithelial malignancy constituting 35.1% of all malignancies, with most patients in advanced stages of the disease. Osteosarcoma was the most frequently diagnosed sarcoma, constituting 11.7% of all malignancies seen. Salivary gland malignancies constituted 29 (37.7%). Other malignancies seen include, malignant peripheral nerve sheath tumor, leiomyosarcoma, and malignant melanoma. Conclusion: OMMs constitute a significant health burden in our region. Thus, adequate resources should be allocated toward improving awareness among the populace. Policy shifts and regular dental visits which may increase the likelihood of early intervention should be instituted.



How to cite this article:
Ibikunle AA, Taiwo AO, Braimah RO. Oral and maxillofacial malignancies: An analysis of 77 cases seen at an academic medical hospital.J Orofac Sci 2016;8:80-85


How to cite this URL:
Ibikunle AA, Taiwo AO, Braimah RO. Oral and maxillofacial malignancies: An analysis of 77 cases seen at an academic medical hospital. J Orofac Sci [serial online] 2016 [cited 2017 Apr 26 ];8:80-85
Available from: http://www.jofs.in/text.asp?2016/8/2/80/195919


Full Text

 Introduction



Oral and maxillofacial malignancies (OMMs) are malignancies affecting the oral and/or the maxillofacial regions often involving the oral mucosa or underlying structures in the area between the vermillion border of the lip and the faucial pillars superolaterally and the base of the tongue inferiorly. Others structures typically involved include the maxilla, mandible, other facial skeleton and face, facial skin, its skeleton, and salivary glands.

OMMs are associated with significant cosmetic and functional limitations.[1],[2],[3] In addition, both the presence of OMM and its treatment often result in significant deterioration in the patient's quality of life.[4] Several descriptive studies on OMM have focused on the pediatric population; few have explored data of the adult age groups, especially in Sub-Saharan Africa. Epidemiological data on OMMs are generally scarce, especially from developing countries of Sub-Saharan Africa. Hence, this study aims to describe the pattern of OMMs in Usmanu Danfodiyo University Teaching Hospital (UDUTH).

 Materials and Methods



This was a review of hospital records of all patients with histologically diagnosed primary oral and/or maxillofacial malignancy who presented to the Department of Dental and Maxillofacial Surgery, UDUTH, over a 6-year period (January 2010 to January 2015). UDUTH is a 1000-bed capacity tertiary regional referral center. It is located in the remote corner of Northwestern part of Nigeria and serves a population of about 26 million from within Nigeria and the neighboring countries of Niger and Benin republic.

The extents of the lesions were determined by visual and radiological examination, including the use of plain radiographs, ultrasound scan, and computed tomography scan. Histological diagnoses were obtained by incisional or excisional biopsy. Data including gender, age, site and type of tumor, and histological grade where applicable, were retrieved from the case notes of patients and analyzed with IBM SPSS statistics for windows version 20 (Armonk, NY: IBM Corp)” software.

 Results



A total of 204 oral maxillofacial tumors were diagnosed over the study period of 5 years with 77 (37.8%) diagnosed as malignancies. There were 38 (49.4%) males and 39 (50.7%) females (male:female = 1:1.03) [Figure 1]. The age of the patients ranged from 2 to 78 years (mean age 50.1 years, ±17.8 standard deviation [SD]) [Table 1]. The modal age of presentation was the third decade of life. Fifty three (68.8%) of the lesions were determined to have affected both soft and hard tissues, whereas 24 (31.2%) cases affected the soft tissues only, with the buccal mucosa most frequently involved [Table 2]. All primary intrabony tumors were located in the molar/ramus area of the mandible and the maxillary antrum.{Figure 1}{Table 1}{Table 2}

Squamous cell carcinoma (SCC) was the most common malignancy 27 (35.1%), with the moderately differentiated histological grade constituting 14 (51.9%) of the SCC cases reviewed [Figure 2] and [Table 3]. Majority of the patients diagnosed with SCC were at least 40 years of age (20 [74.1%]) (mean [±SD] = 52.1 [14.6]). Most of the patients diagnosed with SCC were in Stages III and IV, indicating late hospital presentation [Figure 3]. The gingivae was the most frequent site for SCC [Figure 4].{Figure 2}{Table 3}{Figure 3}{Figure 4}

Osteogenic sarcoma 9 (11.7%) was the most commonly diagnosed sarcoma, with mean age (±SD) of 34.3 (±21.7) years [Table 1]. The most frequent site of occurrence for sarcomas was the mandible [Figure 5]. Rhabdomyosarcoma and Burkitt's lymphoma were seen exclusively in patients in their first or second decade of life. The mean (±SD) age for patients diagnosed with Rhabdomyosarcoma and Burkitt's lymphoma was 7 (±4.6) and 11 (±1.9), respectively [Table 1].{Figure 5}

Salivary gland malignancies constituted 29 (37.7%), with mucoepidermoid carcinoma (MEC) occurring most frequently [Table 1]. The mean age (±SD) of occurrence was 39.9 (±19.2). There was a male preponderance with a male:female ratio of 1:0.4. The histological grades of MEC seen were almost evenly distributed among the high (35.7%), intermediate (35.7%), and low grades (28.6%). The most frequent site of occurrence for salivary malignancies is the palate [Figure 6]. However, the maxillary antrum was the most common site for MEC being the site of occurrence in 50% of cases [Figure 6]. Other relatively rare malignancies such as malignant peripheral nerve sheath tumor, leiomyosarcoma, and malignant melanoma were also seen.{Figure 6}

 Discussion



A variety of tumors were seen in this study with malignancies constituting a significant proportion of the tumors seen. The frequency of malignancies observed is higher than other reports in the literature such as that by Jaafari-Ashkavandi and Ashraf, who observed malignancies in 24.6% of the orofacial tumors studied.[5]

There was an almost equal sex distribution in this study, which contrasts with Abdulai et al., which gave a male to female ratio of 1.86:1.[6] However, the overall mean age seen in this series is similar to the report by Ali and Sundaram.[7] Majority of the malignancies seen involved both soft and hard tissues as a result of contiguous spread, which may be attributed to late presentation by patients.

Malignant epithelial lesions were the most common malignancies, with SCC making up over 95% of the malignant epithelial lesions seen. This is in conformity with other reports in the literature.[7],[8],[9],[10] Furthermore, the proportion of oral SCC in comparison to other malignancies was quite high and this may be a reflection of increasing use of tobacco in its various forms, among the populace.[11],[12] Tobacco alone or in synergy with alcohol predispose to the development of SCC.[13],[14] In addition, there is evidence that heavy drinkers have a 30 times greater risk of developing oral and oropharyngeal cancer.[15],[16],[17] It has been reported that the most common site for intraoral malignancies is the tongue.[18],[19] In contrast to these reports, the buccal mucosa and gingivae were the most common sites of intraoral epithelial malignancies in this study. This may be attributed to the use of smokeless tobacco which may be placed in the buccal vestibule to produce a sustained release of nicotine.[20],[21],[22]

The lower lip was identified as a common site for SCC in this study, no case of primary involvement of the upper lip was identified. Remarkably, all the patients with SCC of the lower lip were males, this may be an indication of the detrimental effects of excessive exposure to ultraviolet rays by patients in a community where about 70% of the population are engage in agriculture and are thus exposed to sunlight more than others.[23],[24] In addition, this study was done in Northern Nigeria where the weather is drier and sunnier.[25] The upper lip may have been uninvolved because the nasal pyramid and its soft tissue structure offer some protection to the upper lip, furthermore the anatomical prominence of the lower lip gives it greater exposure to sunlight.

A vast majority of the patients with SCC were in Stages III and IV of the disease at diagnosis, which is indicative of late hospital presentation. This contrasts sharply with the reports of Gorsky and Dayan and Seoane-Romero et al., who reported late presentation in 25% and 54.5% of the patients studied, respectively.[26],[27] Nevertheless, late presentation as seen in this study was alluded to by other authors.[1],[28] Patients in developing countries like ours often seek conventional treatment after having exhausted other alternatives such as traditional healers and local chemists. Furthermore, the frequency of occurrence of these lesions in relatively obscure sites such as the retromolar trigone, may have contributed to late presentation. Hence, they often present with massive tumors whose initial site is difficult to assess. However, malignancies of the lip, tongue, or buccal mucosa have been associated with relatively early presentation, perhaps because of better visibility.[27]

Sub-types of SCC such as verrucous carcinoma were infrequently seen, similar to reports by Akhtar et al., but in sharp contrast with the report of Khandekar et al.[29],[30] No case of basal cell carcinoma (BCC) was identified, which is in sharp contrast to the reports by Lohmann and Solomon, and Chung, who observed more cases of BCC than SCC.[31],[32] This may be related to the fact that the population studied by them consisted mainly of Caucasians, who are mostly fair skinned, unlike this study which examined records from a West-African population. Furthermore, this study lends credence to reports that SCC is the most prevalent epithelial malignancy of the orofacial region.[33],[34] Moderately differentiated SCC was most frequently seen which is in consonance with the report by Agarwal et al., who analyzed 42 cases.[34] In this study, 32.1% of the SCC was well differentiated, which contrasts heavily with the study of Agarwal et al., who found no case in this category.[34]

Sarcomas accounted for most of the mesenchymal tumors seen. In this series, majority of the sarcomas were osteosarcomas, which were seen most frequently in the mandible. Markedly, some authors deem it to be a rare malignancy.[35] The mean age at presentation differs from reported peak age of incidence in literature, perhaps because this study analyzed cases of osteosarcoma of the maxillofacial region.[36],[37] However, it is consistent with reported figures in the literature for osteosarcoma of the jaws.[35] Three of the patients were children, which is inconsistent with reports in the literature, where various authors suggest that it is very rarely seen in children.[35],[38],[39] Rhabdomyosarcoma was seen exclusively in patients in their first decade of life, which is similar to the reports in the literature.[40],[41]

Burkitt's lymphoma was the most common lymphoproliferative tumor seen, most of which affected the mandible and/or maxilla. The high proportion of Burkitt's lymphoma observed is dissimilar to reports from studies in the Western world but similar to African studies.[42],[43] This finding may be related to the fact that this study was done in a malaria endemic region which predisposes to development of this lesion.[44],[45] Indeed, racial influences on the epidemiology of Burkitt's lymphoma have been alluded to.[42]

MEC was the most frequently diagnosed malignant salivary gland lesion, affecting the antrum in slightly less than half of the cases. This observation is in agreement with reports in the literature.[46],[47] The mean age of the patients was much lower than values reported by Ozawa et al., who reported a mean age of 55.2 years in an analysis of 43 cases.[48] This disparity may be due to the lower number of cases reviewed in this study. In addition, there was a male preponderance, which is in agreement with reports in the literature.[49] The intermediate histologic grade was observed in patients with a lower age group than patients with low or high grade MEC. This is at variance with reports in literature.[50]

One case of central MEC of high histopathologic grade, affecting the mandible in a 73-year-old male was encountered in this study. Central MEC is a rare lesion which occurs more frequently in males.[51] They are said to represent less than 3% of all MECS reported and are seen primarily in fourth or fifth decades of life.[51] In contrast to the reports that MEC occurs most frequently in the parotids, the maxillary antrum was the site of primary involvement in majority of the cases diagnosed in this study.[48],[52]

Malignant peripheral nerve sheath tumor, leiomyosarcoma, and malignant melanoma were also seen, these are rare tumors, especially in the maxillofacial region. Overall, about a third of the cases reviewed were purely of soft tissue origin, this is in contrast to the report of Jaafari-Ashkavandi and Ashraf, who reported soft tissue lesions as 52% of the tumors seen.[5] This contrast may be because of the late presentation by patients in our environment, thereby allowing secondary involvement of soft tissue by a primary intrabony lesion.

 Conclusion



Epidemiological data often vary across geographical, racial, and gender divides. The present study shows trends similar to those in existing literature; however, a number of variations from existing reports were also identified. The relatively high proportion of malignancies should be noted and appropriate mechanisms toward prevention, early diagnosis, and treatment of disease should be proffered. A nationwide study to determine characteristics of OMMs should be embarked upon and relevant national policies formulated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Arotiba GT, Ladeinde AL, Oyeneyin JO, Nwawolo CC, Banjo AA, Ajayi OF. Malignant orofacial neoplasms in Lagos, Nigeria. East Afr Med J 2006;83:62-8.
2Adebayo ET, Ajike SO, Adekeye EO. Tumours and tumour-like lesions of the oral and perioral structures of Nigerian children. Int J Oral Maxillofac Surg 2001;30:205-8.
3Nzegwu MA, Uguru C, Okafor OC, Ifeoma O, Olusina D. Patterns of oral and jaw tumours seen in eastern Nigeria: A review of sixty cases seen over a 5-year period-1 January 2000 to 31 December 2004. Eur J Cancer Care (Engl) 2008;17:532-4.
4Hertrampf K, Wenz HJ, Lehmann KM, Lorenz W, Koller M. Quality of life of patients with maxillofacial defects after treatment for malignancy. Int J Prosthodont 2004;17:657-65.
5Jaafari-Ashkavandi Z, Ashraf MJ. A clinico-pathologic study of 142 orofacial tumors in children and adolescents in southern Iran. Iran J Pediatr 2011;21:367-72.
6Abdulai AE, Nuamah IK, Gyasi R. Head and neck tumours in Ghanaian children. A 20 year review. Int J Oral Maxillofac Surg 2012;41:1378-82.
7Ali M, Sundaram D. Biopsied oral soft tissue lesions in Kuwait: A six-year retrospective analysis. Med Princ Pract 2012;21:569-75.
8Tay AB. A 5-year survey of oral biopsies in an oral surgical unit in Singapore: 1993-1997. Ann Acad Med Singapore 1999;28:665-71.
9Franklin CD, Jones AV. A survey of oral and maxillofacial pathology specimens submitted by general dental practitioners over a 30-year period. Br Dent J 2006;200:447-50.
10Parkins GE, Armah GA, Tettey Y. Orofacial tumours and tumour-like lesions in Ghana: A 6-year prospective study. Br J Oral Maxillofac Surg 2009;47:550-4.
11Raji MO, Abubakar IS, Oche MO, Kaoje AU. Prevalence and determinants of cigarette smoking among in school adolescents in Sokoto metropolis, Northwest Nigeria. Int J Trop Med 2013;8:81-6.
12Salawu F, Danburam A, Isa B, Agbo J. Cigarette smoking habits among adolescents in northeast Nigeria. Internet J Epidemiol 2010;8:8-11.
13Vargas-Ferreira F, Nedel F, Etges A, Gomes AP, Furuse C, Tarquinio SB. Etiologic factors associated with oral squamous cell carcinoma in non-smokers and non-alcoholic drinkers: A brief approach. Braz Dent J 2012;23:586-90.
14Pelucchi C, Gallus S, Garavello W, Bosetti C, La Vecchia C. Alcohol and tobacco use, and cancer risk for upper aerodigestive tract and liver. Eur J Cancer Prev 2008;17:340-4.
15Andre K, Schraub S, Mercier M, Bontemps P. Role of alcohol and tobacco in the aetiology of head and neck cancer: A case-control study in the Doubs region of France. Eur J Cancer B Oral Oncol 1995;31:301-9.
16Ogden GR. Alcohol and oral cancer. Alcohol 2005;35:169-73.
17Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg RS, Preston-Martin S, et al. Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Res 1988;48:3282-7.
18Orbak R, Bayraktar C, Kavrut F, Gündogdu C. Poor oral hygiene and dental trauma as the precipitating factors of squamous cell carcinoma. Oral Oncol Extra 2005;41:109-13.
19Sugerman PB, Savage NW. Current concepts in oral cancer. Aust Dent J 1999;44:147-56.
20Zhou J, Michaud DS, Langevin SM, McClean MD, Eliot M, Kelsey KT. Smokeless tobacco and risk of head and neck cancer: Evidence from a case-control study in New England. Int J Cancer 2013;132:1911-7.
21Boffetta P, Hecht S, Gray N, Gupta P, Straif K. Smokeless tobacco and cancer. Lancet Oncol 2008;9:667-75.
22Weitkunat R, Sanders E, Lee PN. Meta-analysis of the relation between European and American smokeless tobacco and oral cancer. BMC Public Health 2007;7:334.
23Olajide OT, Akinlabi BH, Tijani AA. Agriculture resource and economic growth in Nigeria. Eur Sci J 2012;8:22.
24Ogbalubi LN, Wokocha CC. Agricultural development and employment generation: The Nigeria experience. IOSR J Agric Vet Sci 2013;2:60-9.
25Wright CY, Norval M, Summers B, Davids L, Coetzee G, Oriowo MO. The impact of solar ultraviolet radiation on human health in Sub-Saharan Africa. S Afr J Sci 2012;108:45-50.
26Seoane-Romero JM, Vázquez-Mahía I, Seoane J, Varela-Centelles P, Tomás I, López-Cedrún JL. Factors related to late stage diagnosis of oral squamous cell carcinoma. Med Oral Patol Oral Cir Bucal 2012;17:e35-40.
27Gorsky M, Dayan D. Referral delay in diagnosis of oro/oropharyngeal cancer in Israel. Eur J Cancer B Oral Oncol 1995;31:166-8.
28Aregbesola SB, Ugboko VI, Akinwande JA, Arole GF, Fagade OO. Orofacial tumours in suburban Nigerian children and adolescents. Br J Oral Maxillofac Surg 2005;43:226-31.
29Akhtar S, Sheikh AA, Qureshi HU. Chewing areca nut, betel quid, oral snuff, cigarette smoking and the risk of oesophageal squamous-cell carcinoma in South Asians: A multicentre case-control study. Eur J Cancer 2012;48:655-61.
30Khandekar SP, Bagdey PS, Tiwari RR. Oral cancer and some epidemiological factors: A hospital based study. Indian J Community Med 2006;31:157-9.
31Lohmann CM, Solomon AR. Clinicopathologic variants of cutaneous squamous cell carcinoma. Adv Anat Pathol 2001;8:27-36.
32Chung S. Basal cell carcinoma. Arch Plast Surg 2012;39:166-70.
33Andisheh Tadbir A, Mehrabani D, Heydari ST. Primary malignant tumors of orofacial origin in Iran. J Craniofac Surg 2008;19:1538-41.
34Agarwal AK, Sethi A, Sareen D, Dhingra S. Oral and oropharyngeal squamous cell carcinoma in our population: The clinic-pathological and morphological description of 153 cases. Int J Morphol 2011;29:686-93.
35Kalburge JV, Sahuji SK, Kalburge V, Kini Y. Osteosarcoma of mandible. J Clin Diagn Res 2012;6:1597-9.
36Mirabello L, Troisi RJ, Savage SA. Osteosarcoma incidence and survival rates from 1973 to 2004: Data from the Surveillance, Epidemiology, and End Results Program. Cancer 2009;115:1531-43.
37Ottaviani G, Jaffe N. The epidemiology of osteosarcoma. Cancer Treatment and Res 2009;152:3-13.
38Nthumba PM. Osteosarcoma of the jaws: A review of literature and a case report on synchronous multicentric osteosarcomas. World J Surg Oncol 2012;10:240.
39Ogunlewe MO, Ajayi OF, Adeyemo WL, Ladeinde AL, James O. Osteogenic sarcoma of the jaw bones: A single institution experience over a 21-year period. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:76-81.
40Pastore G, Peris-Bonet R, Carli M, Martínez-García C, Sánchez de Toledo J, Steliarova-Foucher E. Childhood soft tissue sarcomas incidence and survival in European children (1978-1997): Report from the Automated Childhood Cancer Information System project. Eur J Cancer 2006;42:2136-49.
41Dagher R, Helman L. Rhabdomyosarcoma: An overview. Oncologist 1999;4:34-44.
42Stefan DC, Lutchman R. Burkitt lymphoma: Epidemiological features and survival in a South African centre. Infect Agent Cancer 2014;9:19.
43Kaatsch P. Epidemiology of childhood cancer. Cancer Treat Rev 2010;36:277-85.
44Johnston WT, Mutalima N, Sun D, Emmanuel B, Bhatia K, Aka P, et al. Relationship between Plasmodium falciparum malaria prevalence, genetic diversity and endemic Burkitt lymphoma in Malawi. Sci Rep 2014;4:3741.
45Moormann AM, Snider CJ, Chelimo K. The company malaria keeps: How co-infection with Epstein-Barr virus leads to endemic Burkitt lymphoma. Curr Opin Infect Dis 2011;24:435-41.
46Waldron CA, el-Mofty SK, Gnepp DR. Tumors of the intraoral minor salivary glands: A demographic and histologic study of 426 cases. Oral Surg Oral Med Oral Pathol 1988;66:323-33.
47Sengul F, Simsek S, Cakur B. Mucoepidermoid carcinoma in a minor salivary gland in a child. Case Rep Dent 2013;2013:615948.
48Ozawa H, Tomita T, Sakamoto K, Tagawa T, Fujii R, Kanzaki S, et al. Mucoepidermoid carcinoma of the head and neck: Clinical analysis of 43 patients. Jpn J Clin Oncol 2008;38:414-8.
49Oliveira LR, Soave DF, Oliveira-Costa JP, Zorgetto VA, Ribeiro-Silva A. Prognostic factors in patients with malignant salivary gland neoplasms in a Brazilian population. Asian Pac J Cancer Prev 2011;12:363-8.
50Kolude B, Lawoyin JO, Akang EE. Mucoepidermoid carcinoma of the oral cavity. J Natl Med Assoc 2001;93:178-84.
51Kochaji N, Goossens A, Bottenberg P. Central mucoepidermoid carcinoma: Case report, literature review for missing and available information and guideline proposal for coming case reports. Oral Oncol Extra 2004;40:95-105.
52Boahene DK, Olsen KD, Lewis JE, Pinheiro AD, Pankratz VS, Bagniewski SM. Mucoepidermoid carcinoma of the parotid gland: The Mayo clinic experience. Arch Otolaryngol Head Neck Surg 2004;130:849-56.