International Journal of Otorhinolaryngology and Head and Neck Surgery

Kumar KSD et al. Int J Otorhinolaryngol Head Neck Surg. 2019 Jul;5(4):997-1004

http://www.ijorl.com

pISSN 2454-5929 | eISSN 2454-5937

Original Research Article

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20192719

A retrospective study on head and neck malignancies in a tertiary care hospital in Telangana region

K. Samson Deva Kumar, Ivaturi Phani Bhushan*, Novshaba, Chandra Shekhar Annam

Department of ENT, Gandhi Medical College, Secunderabad, Telangana, India

Received: 09 March 2019

Revised: 16 May 2019

Accepted: 17 May 2019

*Correspondence:

Dr. Ivaturi Phani Bhushan,

E-mail: drphani21@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Globally head and neck cancers constitute amongst 10 most common cancers. In Asia especially in India, global head and neck cancers account to 57.5%.However the true incidence of head and neck cancers in India is hidden suggesting it as ‘tip of iceberg’. India is regarded as having the greatest risk of cancer burden, the reason being population overgrowth. India being the country of diversity, varied cultures and traditions, the demographic characteristic of these cancers also vary in different individuals.

Methods: All patients diagnosed with head and neck malignancy after histological confirmation between August 2014 and July 2018 were selected from hospital records. Data regarding age, gender, risk factors, socio economic status, clinical features, staging were taken and statistical analysis was done.

Results: A total of 269 cases were collected out of which, 77% of all malignances in males and 23% in females. Squamous cell carcinoma was the most common histological type (94%). Maximum Incidence of HNC (51.6%) was in 40-60 yrs of age. Tobacco was most prevalent risk factor: 58.36% patients present at early stage, 41.63% present at late stage.

Conclusions: Oral cancers were most common among all. There is male predominance. Tobacco is the most common modifiable risk factor and most patients presenting at an early stage.

Keywords: Head and neck malignancy, Squamous cell carcinoma, Tobacco, Oral cancers

INTRODUCTION

Globally head and neck cancers constitute amongst 10 most common cancers. In developing countries it accounts for the most common cancers especially Southeast Asia.1 In Asia especially in India, global head and neck cancers account to 57.5%. Each year in India nearly 200,000 cases of head and neck cancers occur, of which around 80,000 cases are diagnosed to be oral cavity malignancy.2 However the true incidence of head and neck cancers in India is hidden suggesting it as ‘tip of iceberg’. India is regarded as having the greatest risk of cancer burden, the reason being population overgrowth.3 India being the country of diversity, varied cultures and traditions, the demographic characteristic of these cancers also vary in different individuals.4

Maximum incidence of head and neck cancers occur in 5th–6th decade of life.5 Oral cancers occur after 5th decade,2 oropharyngeal6 and laryngeal in 6th–8th decade,7 sinonasal in 6th and 7th decade,8 salivary gland in 4th – 5th decade,9 nasopharyngeal has bimodal age distribution i.e., 2nd decade and 5th decade of life.10

In India, head and neck cancers accounts to 25% of male cancers and 10% of female cancers.1

Maximum incidence of these cancers is seen in males except for thyroid malignancies which is common in females.1,11

Highest incidence of head and neck cancers is noted in low socio economic status.12

Tobacco smoking and smokeless and chewable forms of tobacco, alcohol consumption are the major contributors to these cancers. Other risk factors include genetic makeup of individual, dietary habits, nutritional deficiencies, chronic infections, poor oral hygiene, ill fitting dentures, occupational exposure and HPV.3

The most common site of head and neck cancer in males is oral cavity, buccogingival sulcus being the commonest subsite.2

Majority of head and neck cancers present to hospital at advanced stage responsible for delay in diagnosis and management, decreasing the survival rate.2 Head and neck cancers constitute one of the leading causes of death both in developed and developing countries.3 Hence screening of high risk individuals and early diagnosis is crucial to decrease the mortality of head and neck cancers.

Aim

To study epidemiological, clinical and histopathological features of head and neck malignancy patients from a tertiary care hospital in Telangana region. To identify the etiological factors, related to life style, causing head and neck malignancy which can be easily modified. To determine the stage of presentation.

METHODS

The retrospective study was conducted in the Department of Otorhinolaryngology, Tertiary Care Hospital, Telangana on 269 cases diagnosed with all head and neck malignancy cases which were proved by histopathological examination, between August 2014 and July 2018.

Inclusion criteria

Inclusion criteria were all malignancy cases of head and neck.

Exclusion criteria

Exclusion criteria were carcinoma unknown primary; cervical esophageal malignancies; from other states.

Data regarding age, gender, risk factors, socio economic status, clinical feature, staging were taken and statistical analysis was done.

RESULTS

Maximal incidence of age in all malignancies is between 41-60 years except non Hodgkins lymphoma where 21-40 years age group is most commonly affected. Males are more commonly affected than females except in thyroid malignancy and non Hodgkins lymphoma. Low socio economic status people are more commonly affected.

Figure 1: Site of malignancy distribution of study population. | 34% 5% 17% 31% 5% 1% 3% 1% 3% 0% 5% 10% 15% 20% 25% 30% 35% 40%
Figure 1: Site of malignancy distribution of study population.
Table 1: Age, gender, socioeconomic status distribution of study population.
Table reproduced from source PDF page 2
Figure 2: Area wise distribution of study population. | 63% 46% 64% 34% 42% 25% 56% 67% 75% 0% 10% 20% 30% 40% 50% 60% 70% 80% Areawise distribution ADB HYD & RR KRN KHM MHB MDK NLG NZB WRL
Figure 2: Area wise distribution of study population.

In most of the malignancies of head and neck tobacco and alcohol are the main risk factors, in thyroid, nasal and nasopharyngeal malignancies radiation plays a causative role.

Most common symptomatology for various head and neck malignancies are ulcerative growth for oral cavity malignancy, discomfort in throat for oropharyngeal malignancy, nasal obstruction and blood tinged nasal discharge for nose paranasal sinuses and nasopharyngeal malignancies, change of voice for laryngeal malignancy, dysphagia for hypopharyngeal malignancy, neck swelling for thyroid malignancy, painless swelling for salivary gland malignancy and non Hodgkins lymphoma.

Most malignancies of oropharynx, nose, paranasal sinus, nasopharynx and NHL presented with cervical lymphadenopathy.

Figure 3: Occupation distribution of study population. | 27% 30% 30% 32% 27% 75% 22% 33.30% 38% 38% 54% 28% 34% 53% 25% 11% 33.30% 25% 0% 10% 20% 30% 40% 50% 60% 70% 80% Occupation distribution Labourer Farmer Mechanic Rickshaw puller Pot worker Shop keeper Others None
Figure 3: Occupation distribution of study population.
Table 2: Risk factors distribution of study population.
Table reproduced from source PDF page 4
Table 3: Clinical presentation distribution of study population.
Table reproduced from source PDF page 4
Figure 4: Location (subsite) distribution of study population. | 33% 46% 70% 45% 53% 100% 56% 100% 49% 15% 17% 52% 21% 44% 4% 8% 13% 3% 5% 4% 0% 20% 40% 60% 80% 100% 120% Oral Cavity Oropharynx Hypopharynx Larynx Nose & PNS Nasopharynx Thyroid Salivary Glands Buccal mucosa Tonsil Piriform fossa Supraglottis Maxillary Sinus Nasopharynx Left lobe Parotid Tongue Base of tongue Post cricoid Glottis Nasal cavity Right lobe Retromolar trigone Soft palate PPW Subglottis Ethmoid sinus Floor of mouth PPW
Figure 4: Location (subsite) distribution of study population.

Lip

Hard palate

Mandibular alveolus

Table 4: Nodal status distribution of study population.
Table reproduced from source PDF page 5
Table 5: Stage of presentation distribution of study population.
Table reproduced from source PDF page 5

Majority of oral, laryngeal and salivary gland malignancies presented in stage 2. Majority of oropharyngeal, hypopharyngeal, nose and PNS presented in stage 3. Nasopharyngeal malignancies presented in stage 2 and stage 3 each accounting to 50%.

In oral, oropharyngeal, hypopharyngeal, laryngeal, nose and PNS, nasopharyngeal malignancies the HPE was suggestive of squamous cell carcinoma in majority of cases (86-100%). In Thyroid malignancies majority are papillary carcinoma (67%). In Salivary gland malignancies majority are mucoepidermoid carcinoma (67%). Suggesting the highest incidence of squamous cell carcinoma in head and neck cancers.

Table 6: Histopathological examination distribution of study population.
Table reproduced from source PDF page 6

DISCUSSION

In the present study 269 cases of head and neck malignancies which presented to tertiary care hospital, Telangana were followed retrospectively.

The following observations were noted based on age distribution of study population (Table 1).

In oral cavity, oropharyngeal, hypopharyngeal, laryngeal, nasopharyngeal, thyroid, salivary gland malignancies maximum incidence was noted in 41–60 yrs of age group accounting to 48%, 54%, 55%, 53%, 75%, 45%, 67% respectively. In sinonasal malignancies maximum incidence was noted in >60 yrs of age group accounting to 54% which is in accordance to Satarkar et al study in which it was common in 6th–7th decades of life.8 In NHL maximum incidence was noted in 21–40 yrs of age group accounting to 50%. Suggesting the maximum incidence of head and neck cancers in the age group of 41–60 years except for NHL and sinonasal malignancies. This is in accordance to Alam et al study in which the incidence was common in 40–60 yrs of age group.13

The following observations were noted based on gender distribution of study population (Table1).

In oral cavity, oropharyngeal, hypopharyngeal, laryngeal, sinonasal, nasopharyngeal, salivary gland malignancies maximum incidence was noted in male gender accounting to 55%, 100%, 62%, 91%, 73%, 75%, 67% respectively. In Thyroid malignancies and NHL the maximum incidence was noted in female gender accounting to 78%, 75% respectively. Suggesting the maximum incidence of head and neck cancers in male gender exception being Thyroid malignancies and NHL. This is in accordance to Francis study in which the highest incidence was noted in males and Carcangiu et al study in which Thyroid malignancies were noted predominantly in females.1,11

The following observations were noted based on Areawise distribution of study population (Figure 2).

In oral cavity, oropharyngeal, hypopharyngeal, laryngeal, sinonasal, thyroid, salivary gland malignancies and NHL maximum incidence was noted in Hyderabad and Rangareddy district accounting to 63%, 46%, 64%, 34%, 42%, 56%, 67%, 75% respectively. Nasopharyngeal malignancies were noted each in Hyderabad and Rangareddy, Mahboobnagar, Nalgonda and Nizamabad each accounting to 25%. Suggesting the maximum incidence of head and neck cancers in Hyderabad and Rangareddy district.

The following observations were noted based on Occupation distribution of study population (Figure 3):

In oral cavity, oropharyngeal, laryngeal, sinonasal malignancies maximum incidence was noted in farmers accounting to 38%, 54%, 34%, 53% respectively. In hypopharyngeal, nasopharyngeal malignancies and NHL maximum incidence was noted in labourers accounting to 30%, 75% 38% respectively. In thyroid malignancies maximum cases fell into none of the above category (45%). Suggesting the maximum incidence of head and neck cancers in farmers and labourers. According to the Socioeconomic status distribution, maximum incidence of head and neck cancers was noted in BPL families (Table 1). This is in accordance to Francis study in which the maximum incidence was noted in BPL families.1

Risk factor distribution in the present study depicted tobacco chewing and alcohol consumption as most common risk factor for Oral malignancies (74%) which is in accordance to Dandekar et al study.4 Beedi/cigarette smoking as most common risk factor for oropharyngeal malignancies (46%) which is in accordance to Alam et al study, alcohol being the most common risk factor for hypopharyngeal malignancies (43%) and smoking + drinking (49%) as most common risk factor for laryngeal malignancies which is in accordance to Maier et al study.13,14

The following observations were noted based on clinical presentation distribution of study population:

The oral malignancies presented as ulcerative growth in majority of cases (78%). The oropharyngeal malignancies presented as discomfort in throat in majority of cases (85%). The hypopharyngeal malignancies presented as dysphagia in majority of cases (72%). The laryngeal malignancies presented as change in voice in majority of cases. The nose and PNS malignancies presented as nasal obstruction (100%) which is in accordance to Lathi et al study followed by blood tinged nasal discharge (67%) in majority of cases.15 The nasopharyngeal malignancies presented as nasal obstruction in 100% of cases followed by epistaxis in 75% of cases. The thyroid malignancies presented as neck swelling in 100% of cases which is in accordance to Pramod et al study.16 100% of salivary gland malignancies presented with swelling. In NHL, all 8 cases presented with swelling (100%) and 2 cases with pain (25%), 1 case with SOB (12.5%), 1 case with difficulty in swallowing (12.5%), 1 case with change of voice (12.5%), 1 case with nasal obstruction (12.5%).

The following observations were noted based on subsite distribution of study population:

The most common subsite for oral malignancies was tongue (49%) which is in accordance to Rivera et al study followed by buccal mucosa (33%).17 The most common subsite for oropharyngeal malignancies was tonsil (46%) followed by posterior pharyngeal wall (31%) which is in accordance to Sanghvi et al.18 The most common subsite for hypopharyngeal malignancies was piriform fossa (70%) followed by post cricoid (17%) which is in accordance to Sanghvi et al.18 The most common subsite for laryngeal malignancies was glottis (52%) followed by supraglottis (45%). The most common subsite for nose and PNS malignancies was maxillary sinus (53%) followed by nasal cavity (21%) which is in accordance to Satarkar et al.8 The most common lobe affected in thyroid malignancies was left lobe (56%). The most common salivary gland involved in malignancies was parotid gland (100%) which is in accordance to Bobati et al.9 The most common site for head and neck cancers was oral cavity in present study which is in accordance to Dandekar et al study.4

The following observations were noted based on nodal status distribution of study population:

In oral, oropharyngeal, hypopharyngeal, laryngeal, nose and PNS, nasopharyngeal malignancies the HPE was suggestive of squamous cell carcinoma in majority of cases accounting 99%, 92%, 100%, 98%, 86%, 100% respectively. In thyroid malignancies HPE was suggestive of papillary carcinoma in 67% of cases. In salivary gland malignancies HPE was suggestive of mucoepidermoid carcinoma in 67% of cases.

The following observations were noted based on stage of presentation distribution of study population:

Majority of oral, laryngeal and salivary gland malignancies presented in stage 2 accounting to 60%, 40%, 100% respectively. Majority of oropharyngeal, hypopharyngeal, nose and PNS presented in stage 3 accounting to 69%, 54%, 60% respectively. Nasopharyngeal malignancies presented in stage 2 and stage 3 each accounting to 50%.

The following observations were noted based on histopathological examination distribution of study population:

In oral, oropharyngeal, hypopharyngeal, laryngeal, nose and PNS, nasopharyngeal malignancies the HPE was suggestive of squamous cell carcinoma in majority of cases accounting 99%, 92%, 100%, 98%, 86%, 100% respectively. In Thyroid malignancies HPE was suggestive of papillary carcinoma in 67% of cases which is in accordance to Rao et al study. In salivary gland malignancies HPE was suggestive of mucoepidermoid carcinoma in 67% of cases. Suggesting the highest incidence of squamous cell carcinoma in head and neck cancers. This is in accordance to Alam et al study in which squamous cell carcinoma was the most common histopathological type.13,18

CONCLUSION

Head and neck cancer accounts for highest incidence in Telangana. The majority of risk factors are related to lifestyle and are modifiable. Screening programmes targeting on high risk individuals who are exposed to risk factors for developing head and neck malignancies are essential for early detection and early treatment thereby decreasing the morbidity associated with it.

Cancer control measurerequires patient education and awareness, active involvement of each and every individual, screening programmes, coordinated research, infrastructure strengthening, resource development to provide utmost benefit to people.

ACKNOWLEDGEMENTS

I would like to thank superintendent of Gandhi Hospital, Head of the Department, ENT, all the supporting staff, last but not the least all the patients who participated in this study and made this study possible and successful.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

  1. 1. Francis D. Trends in incidence of head and neck cancers in India. The 5th Immunotherapy of Cancer Conference. Eur J Cancer. 2018;92(1):1-26.
  2. 2. Kulkarni MR. Head and neck cancer burden in India. Intern J Head Neck Surg. 2013;4(1):29-35.
  3. 3. Mishra A, Meherotra R. Head and Neck Cancer: Global Burden and Regional Trends in India. Asian Pac J Cancer Prev. 2014;15(2):537-50.
  4. 4. Dandekar M, Tuljapurkar V, Dhar H, Panwar A, DCruz AK. Head and neck cancers in India. J Surg Oncol. 2017;115(5):555-63.
  5. 5. National Cancer Registry Programme (ICMR) (2009). Consolidated report of HBCR: 2004-2006. Bangalore, India.
  6. 6. Sharma D, Singh G. Squamous cell carcinoma of the oral cavity and oropharynx in young adults. Indian J Cancer. 2016;53(3):399-401.
  7. 7. Chauhan JPS, Bharti B, Bhadouriya SS, Kumar A, Narain P, Singh J. Laryngeal cancer: A clinicopathological study of 65 cases. Intern J Otolaryngol Head Neck Surg. 2018;4(1):163-8.
  8. 8. Satarkar R, Srikanth S. Tumors and tumor-like conditions of the nasal cavity, paranasal sinuses, and nasopharynx: A study of 206 cases. Indian J Cancer. 2016;53(4):478-82.
  9. 9. Bobati SS, Patil BV, Dombale VD. Histopathological study of salivary gland tumors. J Oral Maxillofac Pathol. 2017;21(1):46-50.
  10. 10. Haleshappa RA, Thanky AH, Kuntegowdanahalli L, Kanakasetty GB, Dasappa L, Jacob L. Epidemiology and outcomes of nasopharyngeal carcinoma: Experience from a regional cancer center in Southern India. South Asian J Cancer. 2017;6(3):122-4.
  11. 11. Carcangiu ML, Zampi G, Pupi A, Castagnoli A, Rosai J. Papillary carcinoma of the thyroid. A clinicopathologic study of 241 cases treated at the University of Florence, Italy. Cancer. 1985;55(4):805-28.
  12. 12. Warnakulasuriya S. Global epidemiology of oral and oropharyngeal cancer. Oral Oncology. 2009;45(4-5):309-16.
  13. 13. Alam MS, Siddiqui SA, Perween R. Epidemiological profile of head and neck cancer patients in Western Uttar Pradesh and analysis of distributions of risk factors in relation to site of tumor. J Cancer Res Ther. 2017;13(3):430-35.
  14. 14. Maier H, Gewelke U, Dietz A, Heller WD. Risk factors of cancer of the larynx: Results of the Heidelberg case: control study. Otolaryngol Head Neck Surg.1992;107(4):577-82.
  15. 15. Lathi A, Syed MM, Kalakoti P, Qutub D, Kishve SP. Clinico-pathological profile of sinonasal masses: A study from a tertiary care hospital of India. Acta Otorhinolaryngologica Italica. 2011;31(6):372-77.
  16. 16. Pramod T, Shivaswamy BS, Ananth G, Rajashekara Babu G, Latha K, Jagadeesh K. Clinical Study of Carcinoma Thyroid and its Management. International J Scientific Study. 2016;3(10):36-42.
  17. 17. Cesar Rivera. Essentials of oral cancer. Int J Clin Exp Pathol. 2015;8(9):11884-94.
  18. 18. Sanghvi LD, Rao DN, Joshi S. Epidemiology of head and neck cancers. Semin Surg Oncol. 1989;5(5):305-9.