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Oral Cancer in Young Adults: Report of Three Cases and Review of the Literature R PRACTICE oral cancer Oral cancer in young adults: report of three cases and review of the literature R. J. Oliver,1 J. Dearing,2 and I. Hindle,3 an area of leukoplakia tender to palpation. Oral cancer in young adults is fortunately uncommon in the UK. At review 1 month later the white patch had However, since it is so rare, when cases present they are often become nodular and the patient was misdiagnosed and inappropriately treated leading to delay in referred. At presentation 3 days later the definitive treatment. This may, in turn, lead to a poorer prognosis symptoms of pain from the left side of the tongue continued, exacerbated by spicy for these patients. It is debatable if oral cancer in younger adults foods but not relieved by empirical treat- carries an inherently poor prognosis and presents with more ments received from the practitioner. Intra- aggressive tumours. Three cases of oral cancer in young adults, orally, a 25 mm diameter white, verrucous aged under 30 years are presented and the literature reviewed area extended from the left lateral margin of with respect to oral cancer in this group of patients. the tongue into the sublingual area which was tender to palpation. The tissue proximal to the lesion was erythematous and atrophic ral cancer (ICD 141, 143-146) contin- We are reporting a series of cases of oral in appearance. Oues to be a serious problem in the UK cancer occurring in three apparently healthy The lesion was biopsied and histopatho- with a steadily rising incidence in certain Caucasian adult patients aged 20, 24 and 26 logical examination revealed a well differen- birth cohorts.1 Despite this, oral cancer years old who presented to one consultant tiated squamous cell carcinoma. The patient remains primarily a disease of older in a 12-month period. underwent total excision of the lesion with patients. Cases occurring in younger adults reconstruction using a split skin graft. At are uncommon, in the region of 1% of oral 5-year follow-up the patient remained free Case reports cancers in England and Wales;2 arbitrarily from disease. a younger age group is referred to as less Case 1 than 30 or 40 years. However, in the major- A 26-year-old married male presented for Case 2 ity of reports as in the present, a group of routine examination with his general dental A 24-year-old married female was referred otherwise apparently healthy young adult practitioner, complaining of a sore area on urgently having presented to her general patients often without any of the usual risk the left side of his tongue, present for about medical practitioner complaining of a lump factors for the development of oral cancer 1 week. There was no relevant medical his- under her tongue of about 3 weeks dura- are identified. However, even when young tory, and the patient was a non-smoker who tion. On presentation, she admitted to a patients have indulged in the risk factors of drank around 10 units of beer per week. lump on the right side of her tongue which tobacco and alcohol, it is for considerably The practitioner diagnosed a traumatic had previously been asymptomatic but had shorter periods compared with the older ulcer, prescribed triamcinolone in carmel- begun to cause occasional discomfort as it age group. Patients in this younger age lose and a chlorhexidine mouthwash. increased in size. The lump was interfering group are claimed by some to have a more Reviewing the patient 1 week later, the with the patients ability to eat. Previous aggressive disease with a higher incidence ulceration was found to have healed, leaving medical history revealed that the patient of local recurrence or regional lymph node had undergone cervical diathermy to involvement after treatment and a higher remove severely dysplastic cells, which had mortality rate compared with older been diagnosed as CIN III (cervical intra- 3,4 patients while others do not support this In brief epithelial neoplasia grade III). Otherwise notion.5–8 ● Oral cancer chiefly affects older her medical history was clear, and the adults. patient was teetotal but smoked up to 20 ● In younger adults, oral cancer is cigarettes per day. Extraoral examination 1Lecturer, 3Senior Lecturer, Oral Surgery Unit, University Dental Hospital of Manchester, Higher often not considered because of its revealed the presence of right hand side Cambridge Street, Manchester M15 6FH; 2Medical relative infrequency which may lead jugulodigastric lymphadenopathy. Intrao- House Officer, Birmingham Heartlands Hospital, to late referral for treatment. rally there was evidence of swelling on the Bordesley Green, Birmingham B9 5SS ● Young adult patients who develop right lower lateral border of the tongue Correspondence: Dr Richard Oliver, Dental Medicine oral cancer often are not exposed to extending into the floor of the mouth, and Surgery, University Dental Hospital, Higher the traditional risk factors of tobacco Cambridge Street, Manchester M15 6FH and alcohol. which was tender and indurated (Figure 1). email: [email protected] There was no fixation of the mass to the REFEREED PAPER Received 15.06.99; accepted 22.11.99 mandible. An incisional biopsy was per- © British Dental Journal 2000; 188: 362–366 formed and histopathologically demon- 362 BRITISH DENTAL JOURNAL, VOLUME 188, NO. 7, APRIL 8 2000 PRACTICE oral cancer and posteriorly to the fauces without tonsil- lar involvement. Isotope bone scan and chest CT were clear, but MRI demonstrated abnormalities in the right jugulodigastric lymph nodes. Despite radical surgery and radiotherapy the patient died 5.5 months after presenta- tion. Discussion Fig. 1 Lesion on the right lateral border of the Oral cancer in young adults is uncommon tongue of Case 2 and therefore case reports claiming its (24-year-old female) aggressiveness can be regarded as little more than anecdotal because of insufficient num- bers to prove this hypothesis scientifically. strated well differentiated squamous cell complaining of a lump on her tongue, was The incidence of oral cancer is increasing in carcinoma. reassured and dismissed. A further 2 some cohorts of patients towards the Bone scans and chest computed tomo- months later the patient attended her local younger end of the group of patients who gram (CT) were clear. CT revealed two accident and emergency department for develop oral cancer (those more than 40 abnormal nodes in the right jugulodigastric treatment of a sudden haemorrhage from years);1 the numbers of cases in young region and one on the left which were nee- the right side of her tongue. The haemor- adults less than 40 years of age are so few it is dle biopsied; the left hand side node was rhage was arrested and the patient dis- not possible at the present time to say if the negative but the right nodes showed charged with no advice to seek further incidence in this age group is actually metastatic squamous cell carcinoma. Fol- assistance. Two days later she presented suf- increasing. Clinical experience tells us that lowing surgery and radiotherapy the patient fering from marked dysarthria and dyspha- young adults presenting with and treated was still alive and well with no evidence of gia. Extraoral examination revealed a for this disease often have extensive primary recurrent disease more than 5 years after tender, hard, enlarged right jugulodigastric tumours and develop recurrences locally or presentation. She subsequently gave birth to lymph node. Intraoral examination demon- in regional lymph nodes, often succumbing her first child. strated a large, tender, indurated ulcer on to their disease rapidly. However, this is not the right lateral border of the tongue (Figure always the case, as illustrated in the present Case 3 2). The patient was admitted and incisional series. Summarised data of previous studies A 20-year-old female, was referred by her biopsy of the lesion was performed which of oral cancer in young adults is presented in general dental practitioner regarding a histopathologically was squamous cell car- Table 1. 20 mm by 3 mm asymptomatic ulcerative cinoma. Magnetic resonance imaging Sarkaria and Harari reviewed a total of lesion on the right lateral border of the (MRI) showed that the lesion extended 152 cases of oral cancer in patients less tongue. This had been present for 3 weeks mesially to the midline of the tongue, inferi- than 40 years of age reported in the litera- and had gradually reduced in size. The orly to the muscles of the floor of the mouth ture.3 These authors concluded from this patient was unaware of the lesion, which had never caused any symptoms. There was no relevant medical history. The patient consumed minimal alcohol and smoked up to 30 cigarettes per day. Her paternal uncle had died from laryngeal carcinoma. Intrao- rally an erosive lesion of the right lateral margin of the tongue with surrounding areas of hyperkeratinisation was noted. Incisional biopsy of the lesion was per- formed providing a histopathological diag- Fig. 2 Ulcerated lesion on the right lateral border of nosis of erosive lichen planus with no the tongue of Case 3 evidence of neoplasia. (20-year-old female) The patient was reviewed at monthly illustrating that the lesion intervals. Six months post-biopsy she was haemorrhaging prior to taking the biopsy attended her general dental practitioner BRITISH DENTAL JOURNAL, VOLUME 188, NO. 7, APRIL 8 2000 363 PRACTICE oral cancer significant number that 57% experienced failure above the clavicles and that 47% of Table 1 Previous reports of oral cancer in young patients patients died from
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