Tumors and tumor-like lesion of the oral cavity: A study of 100 cases at tertiary care hospital

Introduction: Oral cancer is a major health problem in some parts of the world especially developing countries. Oral cancer is the sixth most common cancer in the world whereas in India it is the most prevalent cancer. In India increase in incidence is seen in states like Uttar Pradesh, Madhya Pradesh, Gujarat, Bihar, and Maharashtra. Material & Methods: A total of 100 cases have been studied over a period of two years & two months. The surgical pathology specimens received for histopathological diagnosis were examined microscopically, and the diagnosis was confirmed. Results: Amongst 100 cases studied, 72 (72%) cases were malignant, 12(12%) were benign, 12 (12%) were tumor-like lesions and 4 (4%) cases were premalignant conditions. The youngest patient was 4 years of age and the oldest of 84 years. The male: female ratio was2.3:1. Tobacco chewing was the commonest habit observed in patients with a malignant tumor. Buccal mucosa was the commonest site of tumors and tumor-like lesions. Conclusions: It is the need of the hour to create awareness among people about the early approach to hospital, maintenance of oral hygiene by cultivating good oral habits, and periodic oral check-ups. of present study squamous cell was the most common malignancy comprising 60 cases (83.33%). Next to squamous cell carcinoma was verrucous carcinoma (5 cases; 6.94%). One case each of sarcomatoid squamous cell carcinoma, basaloid squamous cell carcinoma and rhabdomyosarcoma were studied. Two cases of lymphoma (NHL) and mucoepidermoid carcinoma were studied in present study. of benign lesions according to typing: In the present study cases of benign were studied, of which buccal mucosa and tongue were common sites accounting for 33.33% each. Squamous papilloma was the commonest benign lesion (41.67%). Next was haemangioma (4 cases) and the commonest site was tongue. Two cases of granular cell tumors were studied, where buccal mucosa and gingiva were the common sites for each. One case of chondroma of hard palate was studied in the present study. distribution of tumor-like lesions of the oral cavity: Tumour like lesions showed male preponderance with a male: female ratio of 3:1.Inflammatory lesions and dermoid cysts were exclusively seen in males in the present study. Granuloma pyogenic was seen only in females.


Introduction
Oral cancer is a major health problem in developing countries. Oral cancer is the sixth most common cancer in the world whereas, in India, it is the most prevalent cancer. Data from the National Cancer Registry, Indian Council of Medical Research has confirmed the fact that oral cancer is the most common cancer in India.
In India increase in incidence is seen in states like Uttar Pradesh, Madhya Pradesh, Gujarat, Bihar, and Maharashtra, In addition, the 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 groups of diseases which vary from simple inflammatory diseases to that highly malignant tumor [1,2]. Recent studies suggest that human papillomavirus may be associated with oral and oropharyngeal cancers [3]. Among oral cancer Squamous cell carcinoma accounts for >90% of oral cancers attributing to risk factors like the habit of tobacco chewing, betel nut, and alcohol consumption [4].

Aims and Objectives
To study the actual incidence, age and sex incidence and various histopathological appearance and patterns of tumors of the oral cavity, and their prognostic implications. To study the clinical presentation of the lesions, their various risk factors, and to correlate with histopathological diagnosis.
Inclusion criteria: Patients above 18 years of age having tumor and tumor lesions and history of consumption of tobacco-related products.
Exclusion criteria: The Patients already diagnosed as tumors and tumor-like lesions of the oral cavity and dental lesions are excluded from the study.
Sampling: All the patients reporting during the study period and fulfilling the selection criteria were included in the study. A total of 100 cases were included.

Data collection procedure:
The patients who were admitted in the wards for oral cavity lesions, the clinical assessment, nature, and extent of the lesion were studied in each case prospectively.
Sampling method: Relevant clinical details of cases and important results of investigations, with the detailed gross examination of the specimen, noted in proforma. The surgical pathology specimens received for histopathological diagnosis.
Specimens received in the form of biopsy, surgical specimen, and reference slides. All biopsies were embedded completely after thorough gross examination, resected.
The standard method of H and E stains was performed and the sections were examined microscopically, the special stain has done wherever necessary, and microscopic examination findings were noted and histopathological diagnosis was confirmed.

Results
Among 100 cases studied, 72 (72%) cases were malignant, 12 (12%) were benign, 12 (12%) were tumor-like lesions and 4 (4%) cases were premalignant conditions ( Figure 1).     Table 2 represented, Out of 72 malignant lesions in the present study, in 23 cases (31.94%) buccal mucosa was the commonest site. Gingiva and floor of mouth were the least involved sites in the present study. Site distribution of malignant lesions: In the present study the most common malignancy was Squamous cell carcinoma and site affected was buccal mucosa (16 cases), followed by the tongue (14 cases), lip (8 cases), retromolar trigone (7 cases), hard palate (6 cases), gingiva (5 cases) and floor of mouth (4 cases).

Fig
Among 5 cases of verrucous carcinoma, 3 were located in the buccal mucosa, and the remaining 2 were situated on the tongue. A case of each of sarcomatoid SCC, basaloid SCC and rhabdomyosarcoma was located on buccal mucosa. Both cases of NHL were located on the hard palate. Cases of mucoepidermoid carcinoma were located on buccal mucosa and hard palate each.  Table 3 shows, Out of 60 cases of SCC, 49 (81.67%) were well-differentiated, 9 were (15%) moderately differentiated and only 2 (3.33%) were poorly differentiated Squamous cell carcinoma.
Habits: In the present study of 100 cases, 83 patients gave a history of various habits like smoking, alcohol consumption, and smokeless tobacco in the form of Gutkha and khaini, pan eating (betel nut and lime) and combination of above. These habits were predominantly seen in males. Females were not involved in the habits of smoking and alcohol drinking. Histological typing of malignant lesions: In the present study squamous cell carcinoma was the most common malignancy comprising 60 cases (83.33%). Next to squamous cell carcinoma was verrucous carcinoma (5 cases; 6.94%). One case each of sarcomatoid squamous cell carcinoma, basaloid squamous cell carcinoma and rhabdomyosarcoma were studied. Two cases of lymphoma (NHL) and mucoepidermoid carcinoma were studied in the present study.
Distribution of benign lesions according to histological typing: In the present study 12 cases of benign lesions were studied, of which buccal mucosa and tongue were common sites accounting for 33.33% each. Squamous papilloma was the commonest benign lesion (41.67%). Next was haemangioma (4 cases) and the commonest site was tongue. Two cases of granular cell tumors were studied, where buccal mucosa and gingiva were the common sites for each. One case of chondroma of hard palate was studied in the present study.
Site wise distribution of tumor-like lesions of the oral cavity: In the present study 12 cases of tumor-like lesions were studied. Inflammatory lesions were the commonest tumor-like lesions. They were biopsied with clinical suspicion of malignancy. The lesions were located buccal mucosa, tongue, retromolar trigone, lip andgingiva.3 cases of granuloma pyogenic were situated on the buccal mucosa, lip, and gingiva.

Sex wise distribution of tumor-like lesions of the oral cavity:
Tumour like lesions showed male preponderance with a male: female ratio of 3:1.Inflammatory lesions and dermoid cysts were exclusively seen in males in the present study. Granuloma pyogenic was seen only in females.

Discussion
Higher incidence in developing countries like India is attributing to risk factors like the habit of tobacco chewing, betel nut and alcohol consumption, poor oral hygiene, and less intake of fruits [4].
In our study, we found 72 (72%) malignant cases, 12 (12%) benign lesions, 12 (12%) tumors like lesions, and 4 (4%) epithelial precursor lesions. This is comparable with the above studies of Parikins et al [5], Gupta et al [17], and Atram et al [18], which also show similar findings with our study in which incidence of malignant lesions is more than tumor-like and benign lesions. The present study is hospital-based and carried at a tertiary care center. So that mostly malignant cases being referred at our hospital.
In the present study, peak age incidence was noted in the 6 th decade with the youngest patient of 5 years of age and the oldest of 84 years old. These findings are consistent with Khandekar et al [10] and Masamatti et al [16]. These findings are also consistent with Mehrotra et al [2], Parikh et al [13], Gupta et al [17], Manjit Singh Bal [15] and Ray et al [7], Parkins et al [5] noted in their study that maximum cases occurred in the 4 th -7 th decade. In the present study out of 72 malignant cases, 49 were male and 23 female with a male: female ratio of 2.1:1. This is consistent with Parkins et al [5], Gupta et al [17], and Atram et al [18] which show male: female ratio of 2.3: 1, 2.1:1, and 2.7:1 respectively.
In the present study, the most common site for malignant lesions was buccal mucosa. This finding is consistent with Parikh et al [13] and Gupta et al [17]. However in the study of Atram et al [18], the most common site was tongue. The difference might be due to the different habits of tobacco chewing.
In the present study, the most common presenting complaint was Ulcero-proliferative growth (53 cases) followed by erythematous/leukomatous patch (20), pain (19 cases), difficulty in chewing (18). Some patients also gave a history of swelling and excessive salivation. In the study of Parkins et al [5], the main presenting complaint was mandibular facial swelling (63%), followed by intra-oral swelling (55%), pain (41%). Some patients also presented with ulceration, loosening of teeth.
In the study of N. Riaz [6], mandibular facial swelling (63%), intra-oral swelling (55%), and ulceration of the oral cavity (29%) were the main complaints. Gupta et al [17] stated growth (73.5%), ulcer (35%), and pain (12.5%) as the main presenting complaints in their study. In the study of Masamatti et al [16] Ulcero-proliferative growth was the main presenting symptom, followed by pain, difficulty in chewing. Some patients also presented with a white patch, swelling, mucosal irregularities, and excessive salivation. Thus, the present study is in accordance with Masamatti et al [16] and Gupta et al [17]. Tobacco consumption is a very significant risk factor for oral cancers. Other risk factors are age and male sex. The risk increases further when combined with alcohol. In the present study number of patients gave a history of tobacco consumption in the form of smoking or smokeless tobacco i.e. tobacco chewing. This finding was observed by other workers also.
In the present study, 81.67% of cases of well-differentiated (Grade I) squamous cell carcinoma, 15% of cases of moderately differentiated SCC, and 3.33% poorly differentiated SCC were observed. These findings are consistent with the findings of Atrametal [18].
In the present study, the most common malignancy was squamous cell carcinoma (83.33%), followed by verrucous carcinoma (6.94%). We found 1 case (1.38%) each of the basaloid variant of squamous cell carcinoma, a spindle cell variant of squamous cell carcinoma and rhabdomyosarcoma. 2 cases (2.78%) each of mucoepidermoid carcinoma and Non-Hodgkin's lymphoma were studied. Ahluwalia et al [9] studied 2232 malignant cases of the oral cavity in which they found 2066 cases of SCC, 40 cases of the basaloid variant of squamous cell carcinoma, 4 cases each of lymphoma and mucoepidermoid carcinoma. They also found cases of basal cell carcinoma (66 cases), giant cell tumor (2 cases), adenoid cystic carcinoma (5 cases).
In the present study 4 cases of dysplasia were studied. Peak age incidence in the 5 th decade was noted. All 4 cases were male. The most common site as buccal mucosa followed by tongue and gingiva. Clinically the lesion was presented as white (leukoplakia) or red (erythroplakia) patch.
In the present study incidence of premalignant lesions was 4 %. This correlates with studies of Parikh et al [13], Masamatti et al [16], and Gupta et al [17]. A higher incidence was noted in the study of Mehrotra et al [2] (29.89%). In the study of Mehrotra et al [2] among 344 cases of premalignant lesions, 73.2% were male and 26.7% were females. Gupta et al [17] April, 2020/ Vol 6/ Issue 4 cases of premalignant lesions. The peak age of incidence was in the 5 th decade. 6 cases were makes and 2 were females, the most common site of involvement was buccal mucosa. In the study of Masamatti et al [16] 30 cases of premalignant lesions were studied, 19 were males and 11 were females with peak age incidence in the 5 th decade. Clinically these lesions were presented as mucosal irregularities and white patches. The most common site of involvement was buccal mucosa followed by tongue.
The present study was hospital-based and not community-based. Hence results may vary due to patient selection bias.
In the present study we studied 12 benign lesions, most common benign lesion was squamous papilloma (5 cases, 41.67%) followed by haemangioma (4 cases, 33.33%). Two cases of granular cell tumors and one case of chondroma of hard palate were studied. Parikh et al [13] found 3 benign lesions, 2 cases of squamous papilloma, and 1 case of Neurofibroma. Gupta et al [17] found 5 cases of squamous papilloma, 3 cases of haemangioma, 2 cases of pleomorphic adenoma, and 1 case of basal cell adenoma, fibroma, lipoma, Neurofibromaandschwannoma. Atram et al [18] studied 10 cases of haemangioma, 2 cases of squamous papilloma, and 1 case each of lipoma, Neurofibroma, schwannoma, and nevus. The lesion was associated with cleft palate.
A case of Soft tissue chondroma of hard palate was reported by Paolo Vescovi et al [19], 63 years old man presented with long-standing painless swelling on the hard palate. The study of the youngest patient (7-year-old male) presented with Granuloma pyogenic of the upper lip and the oldest patient (80 years old male) with a mucous retention cyst of the buccal mucosa. Our hospital is tertiary care Centre and mostly malignant cases were referred to our institute. Therefore, the incidence of benign lesions may vary.
In the present study 12 cases of the tumor-like lesion were studied. The most common lesion was non-specific inflammation (6 cases) and 3 cases each of the dermoid cyst and granuloma pyogenic. Manjit Singh Bal et al [15] studied 22 cases of granuloma pyogenic and 13 cases of non-specific inflammation.

Limitations of the study
Ours is the hospital-based study and not communitybased, therefore incidence may vary due to patient selection bias. Also, patients were lost to follow up. So that prognosis of the individual lesion in our study was not studied.

Conclusions
In the present study Squamous cell carcinoma has emerged as a most common malignancy leading to morbidity and mortality; an effective preventive and curative measure is the need for time for preventing its threat to the community. Hence Histopathological examination is required for confirmation.
The present study was conducted at a tertiary care center where the bulk of patients are from the periphery and rural areas. Late presentation to health care centers was observed due to lack of awareness, negligence, and preference for age-old traditional remedies of treatment.
It is the need of the hour to create awareness among people about an early approach to hospital, maintenance of oral hygiene by cultivating good oral habits, and periodic oral check-ups.

What does the study add to the existing knowledge?
The proportion of oral cavity lesions is also increasing among young adults due to habits of tobacco chewing, Gutkha, and smoking. There is a need to educate youngsters by using social media platforms to inoculate healthy lifestyles. The role of NGOs and the government will play a vital and crucial role in the long term for controlling lesions of the oral cavity.