Tumors and Tumor like lesions of the Oral Cavity A Study of 303 Cases

Tumors and Tumor like lesions of the Oral Cavity A Study of 303 Cases Bashar A. Hassawi, Eklas Ali, Nadwa Subhe. Department of pathology, College of Medicine, University of Mosul

Abstract To determine the types and relative frequency of the oral lesions, and to assess their age distribution. A retrospective study was performed in Aljumhori teaching hospital, Al salaam teaching hospital and some private laboratories of Mosul city in Iraq between January 2002 and through December 2006. A total of 303 biopsies were examined. Patient's age and sex, clinical data, site of lesions, and type of operation were retrieved from the request forms manually. The data was analyzed with emphasis on age, sex, and histology. There were 261 (86.3%) benign lesions; 39 (12.8%) malignant lesions and 3 (0.99%) were borderline lesions. 145 (47.8%) were males and158 (52.2%) were females. Among the inflammatory and tumor like lesions pyogenic granuloma was the most frequently encountered (80; 26.4% cases) followed by giant cell epulis and fibroepithelial polyp (42; 13.8%, 40; 13.2%) respectively. Among oral cysts radicular cyst was the major type encountered. Hemangioma and Pleomorphic adenoma (15; 4.9%, 9; 2.9% cases) were the commonest benign tumors respectively. While squamous cell carcinoma was found in 23 (7.6%) cases. Inflammatory and Benign lesions are common pathological findings in oral cavity respectively. Malignant tumors are more frequent after age of 50, were squamous cell carcinomas are the main type and more common in male.

Introduction The oral cavity is the first part of digestive system and there are many types of tissues like bone of mandible and maxilla, epithelial tissue of oral mucosa, minor salivary glands, and odontogenic tissue; it is liable for different types of epithelial, mesenchymal and lymphoid tumors(1). In addition involvement of oral cavity in mastication makes it susceptible for different types of trauma and injury, also the presence of teeth and odontogenic tissue is adding more liability for other group of diseases which are vary from simple inflammatory diseases to that highly malignant tumors. However the most common oral lesions are candidiasis, recurrent herpes, recurrent aphthous stomatitis, mucocele, fibroma, pyogenic granuloma, hairy tongue, lichen planus, and leukoplakia which were confirmed by the large-scale, populationbased screening studies (1, 2). These lesions have been diagnosed clinically without biopsy. Other common lesions that are seen in routine work are those lesions which have arisen from the mandible, include both odontogenic and nonodontogenic origins and have varying degrees of destructive potential,

as well as common benign cystic lesionswhich include periapical (radicular) cysts, follicular (dentigerous) cysts, and odontogenic keratocysts(3,4). The cysts are classified according to the cell of origin, where the majority of these cysts in the jaw arising from odontogenic sources as primary pathology, however, cysts may also arise from prior trauma or surgery (5, 6, and 7). In addition, vascular tumors such as hemangioma and arteriovenous malformations are frequently seen in this site of the body(8). The benign tumors that have arisen from odontogenic structures and from mandible and maxilla include several types like cementoma, ossifying fibroma, Odontogenic myxoma, periapical cemental dysplasia. While the borderline and malignant tumors are ameloblastoma, ameloblastic carcinoma, ameloblastic fibrosarcoma, osteosarcoma, and metastatic tumors. Ameloblastoma is locally invasive tumor, while ameloblastic carcinoma applied for tumors with typical cytological findings of malignancy with or without metastasis. (9, 10, 11). Regarding the malignant epithelial tumor that occurs in this region is squamous cell carcinoma. Approximately three-quarters of the oral and oropharyngeal squamous cell

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Tumors and Tumor like lesions of the Oral Cavity A Study of 303 Cases carcinomas (OOSCCs) occur among those living in developing countries. In South east Asia, OOSCCs account for 40% of all cancers compared with approximately 4% in developed countries (9, 12, 13). In addition to tobacco and alcohol abuse. HPV infection, immunodeficiency, and, possibly, genetic changes represent a risk factors for OOSCCs. Several epidemiologic studies have shown a broad variation in the prevalence of human papilloma virus (HPV) in oral precancerous tissues and oral carcinomas (13,14,15,16). Knowing these etiological factors give a great hope for more accurate and reproducible prediction of malignant lesion. Tumors of the minor salivary glands less commonly seen but it is similar to homonymous lesions of the major salivary glands like pleomorphic adenoma, mucoepidermoid carcinoma, adenoid cystic carcinoma and adenocarcinoma(5).

inflammatory conditions and tumor like lesions. 44 cases were odontogenic cysts, nasoalveolar cyst, and bone cysts. 50 cases were benign tumors. While the remaining 42 cases have shown 39 cases of malignant tumors and 3 cases of borderline tumors (table 1). Inflammatory and tumors like lesions are shown in (table 2). Pyogenic granuloma was the major finding comprises 80 cases followed by 40 cases of fibroepithelial polyps. Types and numbers of oral cysts as shown in (table 3) were the radicular cyst is the major type, followed by dentigerous cyst, keratocyst and calcifying Odontogenic cyst. Types of benign tumors are shown in (table 4), include both mesenchymal and epithelial tumors; hemangioma was the commonest one. Malignant tumors was the least, among these squamous cell carcinoma was the highest followed by adenoid cystic carcinoma, Burkitt's lymphoma and other mesenchymal tumors like osteosarcoma (table 5).

Subjects and Methods During a period of 5 years, from January 2002 and through December 2006, 303 cases of primary tumors and tumor like lesions of the oral cavity were collected. The material was obtained from Aljumhori teaching hospital, Al salaam teaching hospital and some private laboratories. The figures represent almost all cases operated upon in Mosul city within the mention period. Patient's age and sex, clinical data, site of lesions, and type of operation were retrieved from the request forms manually. Biopsies were examined grossly concerning the size, and shape of material. The surgical specimens were immediately fixed in 10% formaldehyde, and then the biopsies were routinely processed. One cassette was taken, and the material was embedded in paraffin, and sections were stained with hematoxyline and eosin stains. Microscopical interpretation was then done, and the results were analyzed accordingly.

Results During the period of study, 303 cases of primary tumors and tumor like lesions of the oral cavity were collected. Of these 261 cases were inflammatory and benign lesions including; 167 cases of

Discussion Many studies searching for the types and frequency of the oral lesions were done in this center (17,18), but little is known of these tumors in iraq and this study comes to get more knowledge about lesions of this important site of the body, which included both soft tissue and bone. Although most of the simple infections and inflammatory conditions were treated by physicians at the clinic without biopsy, which constitute the largest group of the oral lesions. However, these lesions were the most frequent types in this study particularly the pyogenic granuloma, giant cell epulis and fibroepithelial polyps which are consistent with others (17, 18, and 19). Sex distribution of pyogenic granuloma and giant cell epulis show female predominance, this may be explained by the fact that hormonal influence may play a role in the growth of these lesions as accelerated growth and recurrence occur during pregnancy and in the postpartum period (20). Radicular cyst 21 cases were the commonest epithelial odontogenic cyst, which is comparable with others. it is important to separate the oral cyst into different histopathological types as some of

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Tumors and Tumor like lesions of the Oral Cavity A Study of 303 Cases them are inflammatory in nature so prevention can be achieved by proper oral hygiene and some can recur after incomplete surgical removal as in cases of keratocyst and aneurysmal bone cyst; and some odontogenic cysts like dentigerous cyst have growth potential and neoplastic transformation in rare cases (21, 22). Benign tumors 50 cases are far more common than malignant tumors 39 cases which are comparable with others (5). Hemangioma 15 cases were found to be the most common pediatric benign tumors of the oral mucosa which is comparable with current study . In some cases, hemangioma, is difficult to differentiate from pyogenic granuloma and vascular malformation depending on histological evaluation alone , so markers specific for benign vascular tumors like GLUT-1 important to differentiate between two entities. (19). Ameloblastoma has seen in three cases. It’s the most frequently encountered tumors arising from odontogenic epithelium, it is locally invasive borderline tumors. The histological types were two follicular and one Plexiform. The estimated relative frequency among jaw tumors is (1%) which is comparable with current study(10,11). Twenty three cases of squamous cell carcinoma form the major category of the malignant oral tumors in the current study. Most of the cases occur in men over the age of 50 years which is comparable with other studies (23, 24), probably because the males are more addict on smoke and alcohol. Oral cavity is the classic location of verrucous carcinoma. Regional lymph node metastasis are exceedingly rare, distant metastasis have not been reported, the most important differential feature with squamous cell carcinoma is the good cytologic differentiation throughout the tumor. Two cases of verrucous carcinoma have been reported in our study (14, 25).

Burkitt’s lymphoma (endemic type) is the most common childhood tumors in central Africa and New guinea, while the relative frequency of Burkitt’s lymphomas of the jaw in our locality and European countries is low (non endemic type)(12) .

Three cases of Burkitt’s lymphoma have been reported in our study, although it’s exceptional, but still there are sporadic cases have reported at this site of the body, were the commonest type is abdominal(26). Benign nodules made of well differentiated lymphocytes are not uncommon in the oral cavity, they are designated as lymphoid polyps five cases of lymphoid polyps are reported in the current study. Minor salivary glands present in all structures within oral cavity. Among benign group Pleomorphic adenoma was encountered in this study showing sex distribution of female to male sex ratio 3:1. Age of occurrence of these tumors was from 20 to 29 years. About (80%) Of salivary gland tumors in the oral cavity are benign, and the Pleomorphic adenoma known as the most common benign intra-oral salivary gland tumor, while mucoepidermoid carcinoma is the most common malignant intra-oral salivary gland tumor. The majority of cases occurred at the palate Among the malignant tumors, adenoid cystic carcinoma and mucoepidermoid carcinoma are the most frequent , all these are comparable with our study (5,27).

Conclusion: Inflammatory and Benign lesions are common pathological findings in oral cavity. Squamous cell carcinoma is the frequent malignant tumor and more common in male. Malignant epithelial and mesenchymal tumors are more frequent in elderly patients.

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Table 1. Histopathological diagnosis of oral lesions with relative frequencies. Type

Number of cases 167

percent

Cysts Benign tumors

44 50

14.5% 16.5%

Border line tumors

3

0.99%

Malignant tumors

39

12.8%

Total

303

100

Inflammatory and Tumor like lesion

55.1%

Table 2. Types and relative frequencies of the inflammatory and tumor like lesions. Type Pyogenic granuloma Giant cell epulis Fibroepithelial Polyp Lymphoid polyp Total

Total 80 42 40 5 167

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Percent 47.9 25.1 23.9 3 100%

Tumors and Tumor like lesions of the Oral Cavity A Study of 303 Cases Table 3. Types and relative frequencies of oral cysts. Types

Total

Percent

Radicular cyst keratocyst Dentigerous cyst Calcifying odontogenic cyst Nasoalveolar cyst Aneurysmal bone cyst Simple bone cyst Total

21 7 8 2 1 3 2 44

47.7 15.9 .118 4.5 2.2 6.8 4.5 100%

Table 4. Types and relative frequencies of benign tumors of the oral cavity Benign tumors

Total

M:F

Percent

Ossifying fibroma Cemintifying fibroma Odontogenic myxoma rhabdomyoma

5 2 3 2

ratio 0.9:1 1:1 1:2 1:1

10 4 6 4

Neurofibroma hemangioma Osteoma Ameloblastic fibroma Pleomorphic adenoma Granular cell tumor cementoma Total

2 15 2 5 9 3 3 50

1:1 1:2 1:1 2:3 1:3 1:2 1:2

4 30 4 8 18 6 6 100%

Table 5. Types and relative frequencies of malignant tumors. Percent

58.9 5.1 10.2 5.1 2.5 7.8 5.1 5.1 100%

M:F ratio 3:1 1:1 1:3 1:1 2:1 1:1 1:1

Total

Malignant tumors

23 2 4 2 1 3 2 2 39

Squamous cell carcinoma Verrocus carcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Kaposi sarcoma Burkitt's lymphoma Embryonal rhabdomyoarcoma Osteosarcoma Total

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Tumors and Tumor like lesions of the Oral Cavity A Study of 303 Cases

Table 6 . Age distribution of the major types of oral lesions. Types

0-10

11-20

21-30

31-40

5160 8

6170 6

7180 7

Total

27

4150 15

Inflammatory and Tumors like lesion Cysts Benign tumors Border line tumors Malignant tumors Total

9

29

66

8

13 15

16 15

11 6 1 1

3 3 2 3

1 2

-

-

4

14

4

44 50 3 39 303

6

1

4

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167