Lifestyles, environmental and phenotypic factors associated with lip cancer: a case-control study in southern Spain

Long-term outcomes, quality of life, and costs of treatment modalities for T1-T2 lip carcinomas

PURPOSE

Early stage lip squamous cell carcinoma (lip SCC) can be treated with conventional excision, Mohs micrographic surgery (MMS), or brachytherapy. The aim of this retrospective study was to describe the medical outcomes, patient-reported outcomes, and costs of these treatments.

METHODS

A retrospective cohort study of T1-T2 lip SSCs treated between 1996 and 2019. Medical outcomes, recurrences, and survival were retrieved from medical records. Facial appearance, facial function, and Quality of Life (QoL) were measured with the Face-Q H&N and EQ-5D-5L questionnaires. Costs were also calculated.

RESULTS

Of the 336 lip SCCs, 122 were treated with excision, 139 with MMS, and 75 with brachytherapy. Locally, the recurrence rate was 2.7% and regionally 4.8%. There were 2% disease-related deaths. T2-stage and poor tumor differentiation were associated with recurrences. Posttreatment QoL, facial function, and appearance were rated as good. Brachytherapy was the most expensive treatment modality.

CONCLUSION

Early-stage lip SCC has a good prognosis, with a disease-specific survival of 98.2% after a median follow-up of 36 months, there was a high QoL and satisfaction at long-term follow-up. Based on the costs and the risk of locoregional recurrences, we believe that, for most noncomplex lip SCCs, MMS would be the most logical treatment option.

Interdisciplinary management of skin cancer

The interdisciplinary treatment of skin cancer in the head and neck area requires close collaboration between different specialist disciplines. The most common non-melanoma skin cancer tumor entities are cutaneous squamous cell carcinoma and basal cell carcinoma as well as their precursor lesions. One of the less common tumors is Merkel cell carcinoma, which also occurs primarily in light-exposed areas and, in contrast to squamous and basal cell carcinoma, is more likely to metastasize. Due to the low tendency of basal cell carcinoma as well as cutaneous squamous cell carcinoma to metastasize, a cure can often be achieved by surgery. If the tumor growth exceeds certain levels it may require collaboration between dermatology and otorhinolaryngology. The primary goal of this interdisciplinary collaboration is to achieve a functional, cosmetically and aesthetically acceptable result in addition to adequate tumor treatment. Depending on the stage of the tumor and the clinical course, a case may be discussed in an interdisciplinary tumor board in order to determine a personalised, appropriate and adequate treatment concept for each patient, including prevention, therapy and follow-up.

Outcomes of Upper Lip Mohs Surgery Repairs Using Standardized Scar Scales With Particular Emphasis on Vermillion Border Involvement

BACKGROUND

The lips are a common location for skin cancer, and thus, a common site for Mohs micrographic surgery (MMS). As an important cosmetic and functional facial unit, MMS defects and reconstruction can affect patient perception on functional and aesthetic outcomes.

OBJECTIVE

The objective of this study was to compare aesthetic and functional outcomes after upper lip MMS between patients with vermillion sparing repairs (VSR) versus vermillion crossing repairs (VCR).

MATERIALS AND METHODS

Patients from a single institution from 2018 to 2022 undergoing MMS of the upper lip with linear or select flap repairs were included. Patients were assessed at a minimum of 6-week follow-up for self-assessment of functional and cosmetic outcomes, as well as physician assessment of scar cosmesis using validated Patient and Observed Scar Assessment Scale and Scar Cosmesis Assessment and Rating scale. The results were compared between VSR and VCR groups.

RESULTS

Forty-five patients were included in this study. No significant difference between patient assessment of functional and cosmetic outcome was identified between VSR and VCR.

CONCLUSION

Patient satisfaction with lip reconstruction can be high. Crossing the vermillion border does not affect patient assessment of aesthetic and functional results and should be considered if needed to optimize reconstructive outcomes.

Disease burden, risk factors, and trends of lip, oral cavity, pharyngeal cancers: A global analysis

BACKGROUND

Lip, oral and pharyngeal cancers make up a small percentage of total cancer cases worldwide and have reported lower rates of cancer-related deaths globally in 2020, but their 5-year survival rate in either early or advanced stages is different. The study evaluated the global incidence, mortality, risk factors, and temporal trends by age, gender, and geographical locations of lip, oral cavity, and pharyngeal cancer.

METHODS

Incidence and mortality rates were extracted from Cancer Incidence in Five Continents (CI5) volumes I-XI, the Nordic Cancer Registries (NORDCAN), the Surveillance, Epidemiology, and End Results (SEER) Program, and the WHO IARC mortality database. Joinpoint regression was used to calculate the Average Annual Percentage Change to examine trends.

RESULTS

The highest incidence rates were found in Melanesia and South-Central Asia and mortality rates were 8.2 and 7.5. Risk factors associated with incidence and mortality included HDI, tobacco use, alcohol consumption, poor diet, and chronic health conditions such as hypertension. Increasing trends of incidence and mortality were observed in females from Malta; males aged 50 and above from the United Kingdom, and females aged 50 and above from Slovakia reporting the largest increase.

CONCLUSIONS

Although global incidence and mortality trends reported an overall decrease, significant increases were found for older age groups and female subjects. Incidence increase may be due to the growing prevalence of lifestyle, metabolic risk factors, and HPV infections, especially in developed countries.

UVR Exposure and Prevention of Street Construction Workers in Colombia and Germany

(1) Solar ultraviolet radiation (UVR) poses a major risk factor for developing skin cancer after years of chronic exposure. The irradiation is strongly dependent upon the activity or occupation carried out, but also on the climate conditions at the workplace. Knowledge of both has been tested within the occupational group of road construction workers in Colombia and Germany. (2) The GENESIS-UV measurement system has been used at both locations for consistency. A number of workers in both countries wore an electronic data logging dosimeter for several months to deliver detailed information on UVR exposure. (3) It was found that in a tropical climate, UVR exposure remains constant throughout the year, while in a temperate climate seasonal effects are visible, superimposed by behavioural aspects e.g., in springtime. The daily distribution of the radiation shows a distinct dip, especially in the Colombian data. Derived data show the high fraction of working days exceeding a threshold set by the skin type. (4) Road construction work involves high UVR exposure. In both countries, preventive measures are required to reduce the personal exposure to a minimum. Exceedance of the minimal erythema dose (MED) suggests a possible enhancing effect, especially in fair skinned people. Intercomparison of UVR exposure at workplaces is possible between countries and climate zones, emphasizing efforts for global action against skin cancer.

Hydrochlorothiazide use is associated with the risk of cutaneous and lip squamous cell carcinoma: A systematic review and meta-analysis

PURPOSE

The aim of this study is to investigate the association between hydrochlorothiazide (HCTZ) use and the risk of cutaneous and lip squamous cell carcinoma development.

METHODOLOGY

We performed a systematic review and meta-analysis of case-control studies. We searched the Cochrane Library, PubMed, Scopus, Web of Science and LILACS. This study was registered in PROSPERO under protocol CRD42019129710. The meta-analysis was performed using the software Stata (version 12.0).

RESULTS

A total of 2181 published studies referring to the theme were identified, from which six were included in this systematic review. Men were more frequently affected by cutaneous and lip squamous cell carcinoma than women, with a 1.42:1 ratio. The mean age for cutaneous and lip squamous cell carcinoma development was 73.7 years. This meta-analysis demonstrated a chance of developing cutaneous and lip squamous cell carcinoma in any region of the body in hydrochlorothiazide users of 1.76-fold higher than in non-users. In addition, a risk factor of 1.80 higher (CI 95% = 1.71-1.89) of cutaneous squamous cell carcinoma in the head and neck region was observed in HCTZ users. Moreover, in the analysis of the dose used, the chance of developing squamous cell carcinoma was 3.37-fold lower when the concentration of HCTZ used was less than 50,000 mg.

CONCLUSIONS

Our results confirm the association between the use of hydrochlorothiazide and the cutaneous and lip squamous cell carcinoma development.

Exposome and Skin. Part 2. The Influential Role of the Exposome, Beyond UVR, in Actinic Keratosis, Bowen's Disease and Squamous Cell Carcinoma: A Proposal

Actinic keratosis (AK) is the main risk factor for the development of cutaneous invasive squamous cell carcinoma (SCC). It represents the first sign of severe chronic ultraviolet radiation exposure, which has a clear significant effect. Nevertheless, the skin is exposed to many other exposome factors which should be thoroughly considered. Our aim was to assess the impact of exposome factors other than ultraviolet radiation (UVR) on the etiopathology of AK and Bowen's disease (BD) and progression of AK to SCC and to design tailored prevention strategies. We performed an exhaustive literature search in September 2021 through PubMed on the impact of exposome factors other than UVR on AK, BD and SCC. We conducted several parallel searches combining terms of the following topics: AK, BD, SCC and microbiome, hormones, nutrition, alcohol, tobacco, viral infections, chemical contaminants and air pollution. Notably, skin microbiome studies have shown how Staphylococcus aureus infections are associated with AK and AK-to-SCC progression by the production of chronic inflammation. Nutritional studies have demonstrated how a caloric restriction in fat intake, oral nicotinamide and moderate consumption of wine significantly reduce the number of premalignant keratoses and SCC. Regarding lifestyle factors, both alcohol and smoking are associated with the development of SCC in a dose-dependent manner. Relevant environmental factors are viral infections and chemical contaminants. Human papillomavirus infections induce deregulation of cellular proliferation and are associated with AK, BD and SCC. In addition to outdoor jobs, occupations such as industrial processing and farming also increase the risk of developing keratoses and SCC. The exposome of AK will undoubtedly help the understanding of its etiopathology and possible progression to SCC and will serve as a basis to design tailored prevention strategies.

Re-Emphasizing the Roles of General Medical and Dental Practitioners Regarding Oral Cancer Eradication in Nigeria

The burden of oral cancer in Nigeria is largely under-reported. The available data on oral cancer etiology/risk factors, clinical features, disease burden, and literacy rate in Nigeria points towards a possible explosion in prevalence in the near future, which poses a serious public health concern. The general medical and dental practitioners (GMDPs) in Nigeria can salvage this looming problem through appropriate public health and clinical interventions. This narrative review article re-emphasizes the key roles of GMDPs towards oral cancer eradication in Nigeria. It also discusses oral cancer case definition, etiology, risk factors, and the epidemiological burden in the Nigerian context.

Ethanol-Induced Cell Damage Can Result in the Development of Oral Tumors

Simple Summary

Alcohol consumption is linked to 26.4% of all lip and oral cavity cancer cases worldwide. Despite this clear causal relationship, the exact molecular mechanisms by which ethanol damages cells are still under investigation. It is well-established that the metabolism of ethanol plays an important role. Ethanol metabolism yields reactive metabolites that can directly damage the DNA. If the damage is repaired incorrectly, mutations can be fixed in the DNA sequence. Whenever mutations affect key regulatory genes, for instance cell cycle regulating genes, uncontrolled cell growth can be the consequence. Recently, global patterns of mutations have been identified. These so-called mutational signatures represent a fingerprint of the different mutational processes over time. Interestingly, there were ethanol-related signatures discovered that did not associate with ethanol metabolism. This finding highlights there might be other molecular effects of ethanol that are yet to be discovered.

Abstract

Alcohol consumption is an underestimated risk factor for the development of precancerous lesions in the oral cavity. Although alcohol is a well-accepted recreational drug, 26.4% of all lip and oral cavity cancers worldwide are related to heavy drinking. Molecular mechanisms underlying this carcinogenic effect of ethanol are still under investigation. An important damaging effect comes from the first metabolite of ethanol, being acetaldehyde. Concentrations of acetaldehyde detected in the oral cavity are relatively high due to the metabolization of ethanol by oral microbes. Acetaldehyde can directly damage the DNA by the formation of mutagenic DNA adducts and interstrand crosslinks. Additionally, ethanol is known to affect epigenetic methylation and acetylation patterns, which are important regulators of gene expression. Ethanol-induced hypomethylation can activate the expression of oncogenes which subsequently can result in malignant transformation. The recent identification of ethanol-related mutational signatures emphasizes the role of acetaldehyde in alcohol-associated carcinogenesis. However, not all signatures associated with alcohol intake also relate to acetaldehyde. This finding highlights that there might be other effects of ethanol yet to be discovered.

Association of Lifetime Indoor Tanning and Subsequent Risk of Cutaneous Squamous Cell Carcinoma

Importance

No study, to our knowledge, has prospectively investigated a dose-response association between lifetime indoor tanning and risk of cutaneous squamous cell carcinoma (SCC).

Objective

To investigate the dose-response association between lifetime indoor tanning and SCC risk, the association between duration of use and age at initiation with SCC risk, and the association between age at initiation and age at diagnosis.

Design, Setting, and Participants

This cohort study included data from women born from 1927 to 1963 from the Norwegian Women and Cancer study, established in 1991 with follow-up through December 31, 2015. Baseline questionnaires were issued to participants from 1991 to 2007, with follow-up questionnaires given every 5 to 7 years. Data analysis was performed from January 2, 2018, to March 2, 2019.

Exposures

Participants reported pigmentation factors. Sunburns, sunbathing vacations, and indoor tanning were reported for childhood, adolescence, and adulthood.

Main Outcomes and Measures

Information on all cancer diagnoses and dates of emigration or death were obtained through linkage to the Cancer Registry of Norway, using the unique personal identification number of Norwegian citizens.

Results

A total of 159 419 women (mean [SD] age at inclusion, 49.9 [8.3] years) were included in the study. During follow-up (mean [SD], 16.5 [6.4] years), 597 women were diagnosed with SCC. Risk of SCC increased with increasing cumulative number of indoor tanning sessions. The adjusted hazard ratio (HR) for highest use vs never use was 1.83 (95% CI, 1.38-2.42; P < .001 for trend). A significantly higher risk of SCC was found among women with 10 years or less of use (HR, 1.41; 95% CI, 1.08-1.85) and more than 10 years of use (HR, 1.43; 95% CI, 1.16-1.76) and among women with age at initiation of 30 years or older (HR, 1.36; 95% CI, 1.11-1.67) and younger than 30 years (HR, 1.51; 95% CI, 1.18-1.92) vs never users. No significant association was found between age at initiation and age at diagnosis (estimated regression coefficient, -0.09 [95% CI, -1.11 to 0.94] for age at initiation of ≥30 years and -0.02 [95% CI, -1.27 to 1.22] for <30 years vs never use).

Conclusion and Relevance

The findings provide supporting evidence that there is a dose-response association between indoor tanning and SCC risk among women. The association between cumulative exposure to indoor tanning and SCC risk was the same regardless of duration of use and age at initiation. These results support development of policies that regulate indoor tanning.

Immunohistochemical analysis of epithelium adjacent to lip cancer: A meta-analysis

OBJECTIVES

To identify the immunohistochemical pattern of non-tumoral epithelium adjacent to lip cancer (ANTE) to unveil molecular alterations and potential biomarkers in lip cancer patients.

MATERIALS AND METHODS

A systematic search at MEDLINE, EMBASE and proceedings Web of Science, OpenGrey and WorldCat. The PICOS outline (Population: lip cancer patients; Intervention: immunostaining with biomarkers in surgical specimens; Comparisons: ANTE versus LC; Outcomes: primary-to identify the immunohistochemical pattern of peritumoral epithelium and secondary-to assess the immunoreactivity of LC epithelium; and Study design: cross-sectional, case-control and cohort studies).

RESULTS

A total of 339 records were identified. Seven studies reporting on ANTE and LCs were included in the qualitative synthesis, and 4 of them (p53 immunostaining) were selected for meta-analysis. In the ANTE group, the pooled prevalence of p53 was 0.74 (95% CI: 0.66 - 0.82), while in the lip squamous cell carcinoma group this prevalence was 0.83 (95% CI: 0.75 - 0.89).

CONCLUSIONS

Similar immunoexpression was found in lip epithelium adjacent to lip carcinoma, even in epithelia with normal appearance or mild histological alterations. The role of biomarkers in the follow-up of actinic cheilitis patients deserves additional clinical assessment.

Demographic and Clinicopathologic Features of Actinic Cheilitis and Lip Squamous Cell Carcinoma: a Brazilian Multicentre Study

Data on the occurrence and clinicopathological characteristics of actinic cheilitis (AC) and lip squamous cell carcinoma (LSCC) are well studied; however, they are based on studies limited to a single centre. Herein, we described the frequency of AC and LSCC submitted to microscopic examination from representative geographic regions of Brazil. A retrospective multicentre study was performed on biopsies obtained from 1953 to 2018 at 10 Brazilian oral and maxillofacial pathology centres. A total of 198,709 biopsy specimens were surveyed. Sociodemographic data and clinicopathologic characteristics were analysed. A total of 2017 cases of ACs (1.0%) and 850 cases of LSCCs (0.4%) were recorded. A strong fair-skinned (> 87%) male (> 70%) predilection was observed in both conditions. The mean age was 54.8 ± 18.7 for individuals with AC and 57.8 ± 19.0 for individuals with LSCC. The most commonly affected site was the lower lip (> 90%). This is a large multicentre study of AC and LSCC from Brazil. The frequency and clinicopathological features of AC and LSCC were similar to those described worldwide. This study provides robust and representative epidemiological data of these conditions for the scientific community.

Adjuvant interstitial three-dimensional pulse-dose-rate-brachytherapy for lip squamous cell carcinoma after surgical resection

Purpose

The purpose of this study was to report clinical outcomes of patients treated with pulse-dose-rate brachytherapy (PDR-BT) for lip cancer after insufficient surgery.

Material and methods

Twenty lip cancer patients were treated from January 2012 to September 2016. Primary treatment included surgery with or without reconstruction. All patients were diagnosed with squamous cell carcinoma, most of the tumors were pT1. Brachytherapy procedures were done after post-operative wound healing. Median of three plastic tubes were implanted using a free-hand technique. Two PDR-BT treatments were scheduled for every patient, with the gap of median 13 days. The planned dose was 0.8-1 Gy per pulse to the total dose of 50 Gy from two PDR-BT treatments. Patients were evaluated every 3-6 months. Follow-up time was counted from the last day of treatment to any event or last visit. Early and late toxicities were scored with RTOG scale.

Results

Average follow-up was 34.7 months (range, 12.7-67.6). Three- and five-year estimated disease-free survival was 95% and local control was 100%. One patient suffered from regional relapse in the submental region (IA lymph node group). Skin erythema or dry desquamation (grade 1) or wet desquamation (grade 2) was observed in 13 patients (65%) and one patient (5%), respectively. Six patients presented no acute toxicity. Moreover, there were no complications involving lip mucosa. All patients had grade 1 soft tissue fibrosis in the irradiated area, besides that, late toxicity included only skin complications. There were no significant factors associated with late toxicity ≥ grade 2.

Conclusions

PDR-BT in the adjuvant treatment of the lip cancer yields high local control with low toxicity. Even patients with close margins after surgery (< 5 mm) should be considered as candidates for PDR-BT.

Characteristics of non-melanoma skin cancers of the cutaneous perioral and vermilion lip treated by Mohs micrographic surgery

BACKGROUND

The lip and surrounding perioral region are susceptible to non-melanoma skin cancer, but the distribution of basal cell and squamous cell carcinoma on the cutaneous and vermilion lips has not been fully elucidated.

OBJECTIVE

To investigate the distribution of cutaneous and vermilion lip non-melanoma skin cancer and to better describe risk factors, anatomic location, treatment characteristics and oncologic outcomes.

METHODS

A retrospective comparative case series of patients undergoing Mohs micrographic surgery (MMS) at a single academic centre for lip and perioral basal cell and squamous cell carcinoma was performed over a 5-year period. Demographics, medical comorbidities, surgical characteristics and recurrence status were extracted.

RESULTS

Forty-five vermilion and 116 cutaneous lip cancers were identified. Basal cell carcinoma (BCC) was more common in the cutaneous perioral region, while squamous cell carcinoma (SCC) was more common on the vermilion lip (P < 0.001). BCCs were more common on the upper vermilion lip and SCCs were more common on the lower vermilion lip (P < 0.001). Within the cutaneous perioral region, both BCCs and SCCs were more common on the upper perioral surface (P = 0.002). Male gender was associated with lower lip SCC (P = 0.015). Smoking, immunosuppression, anticoagulant use and hydrochlorothiazide use were not associated with cancer type or location. Recurrences were rare, but more common in vermilion lip cancers (6.6%) compared to perioral cutaneous cancers (0.8%). Outcomes for all groups were similar; BCCs of the vermilion lip had significantly greater mean MMS stages (P < 0.001) as did SCCs (P = 0.05).

CONCLUSION

Basal cell carcinoma is more commonly encountered on the cutaneous lip, whereas SCC is more common on the vermilion lip. Within the vermilion lip, BCC favours the upper lip, while SCC favours the lower lip. Within the cutaneous perioral region, both BCC and SCC favour the upper cutaneous tissue. Early stage lip cancers are curable by Mohs micrographic surgery with rare recurrences.

Epidemiological Aspects in Lip Tumors in Oltenia Region of Romania During 2012-2016

Purpose. The objective of this study was to review lip tumor diagnosed subjects from Oltenia region, in the past 5 years according to gender, age, home environment, profession, geographic area, smoking habit, associated diseases, tumor location, macroscopic aspect and histological type. Material and Methods. The study was done at the Oral and Maxillo-Facial Clinic of the Emergency Clinical County Hospital of Craiova, and involved the analysis of patient file records, surgical registers, histopathological bulletins, from 2012-2016. Results. Of the 175 subjects included in this study, all of them diagnosed with lip tumor pathology, 109 (62.29%) were men, and 66 (37.71%) were women, all of them with ages between 6 and 92 years, with a mean age of 61 years. Distribution of study participants according to the home residence showed that majority of the subjects lived in rural area. The most frequently localization of lip tumors in study participants was at the lower lip-140 cases (80%), than at the upper lip-35 cases (20%).According to histological characteristics, distribution of the malignant lip tumors was 87.39%-squamous cell carcinoma (SCC), 5.41%-basal cell carcinoma (BCC) and 7.20%-other type of tumors. Conclusions. The lower lip was the most affected, by lip cancer, and squamous cell carcinoma represents the most frequently histological type of these tumors.

The Correlation between the Complexity of the Reconstruction in the Labial Region and the Extent of the Postoperative Defect - Report of 3 Cases

Lips are structures that play an essential role in aesthetics, nutrition and speech. Their complex anatomy-with three different layers composed of skin, mucosa, and muscles-makes surgical management of this area a therapeutic challenge. We report here 3 cases of surgical reconstruction of the upper lip after the excision of tumors of varying sizes. The resulted defect from tumor extirpation is always closely linked to the time elapsed from the appearance of the tumor to the presentation in the ambulatory of Oral and Maxillofacial Surgery.

The global incidence of lip, oral cavity, and pharyngeal cancers by subsite in 2012

By using data from the International Agency for Research on Cancer publication Cancer Incidence in 5 Continents and GLOBOCAN, this report provides the first consolidated global estimation of the subsite distribution of new cases of lip, oral cavity, and pharyngeal cancers by country, sex, and age for the year 2012. Major geographically based, sex-based, and age-based variations in the incidence of lip, oral cavity, and pharyngeal cancers by subsite were observed. Lip cancers were highly frequent in Australia (associated with solar radiation) and in central and eastern Europe (associated with tobacco smoking). Cancers of the oral cavity and hypopharynx were highly common in south-central Asia, especially in India (associated with smokeless tobacco, bidi, and betel-quid use). Rates of oropharyngeal cancers were elevated in northern America and Europe, notably in Hungary, Slovakia, Germany, and France and were associated with alcohol use, tobacco smoking, and human papillomavirus infection. Nasopharyngeal cancers were most common in northern Africa and eastern/southeast Asia, indicative of genetic susceptibility combined with Epstein-Barr virus infection and early life carcinogenic exposures (nitrosamines and salted foods). The global incidence of lip, oral cavity, and pharyngeal cancers of 529,500, corresponding to 3.8% of all cancer cases, is predicted to rise by 62% to 856,000 cases by 2035 because of changes in demographics. Given the rising incidence of lip, oral cavity, and pharyngeal cancers and the variations in incidence by subsites across world regions and countries, there is a need for local, tailored approaches to prevention, screening, and treatment interventions that will optimally reduce the lip, oral cavity, and pharyngeal cancer burden in future decades. CA Cancer J Clin 2017;67:51-64. © 2016 American Cancer Society.

Early stage squamous cell carcinoma of the lower lip: predictive factors for recurrence

Objective:

This study aimed to evaluate the effect of tumour thickness on other clinicopathological parameters in early stage lower lip squamous cell carcinoma.

Methods:

Forty-six consecutive patients with lower lip squamous cell carcinoma were included in the study. Demographic, clinical and pathological data were retrospectively collected.

Results:

The mean follow-up period for all patients was 32.0 ± 18.9 months. Forty-four tumours were staged as T1 and two were T2. Twelve patients underwent neck dissection. Two patients presented with neck metastasis in the follow-up period. Four patients (8.7 per cent) had local recurrence. Correlation analysis revealed a significant relationship between microscopic tumour thickness and local tumour recurrence (r = 0.328, p = 0.045).

Conclusion:

Surgical margin control is important to prevent local recurrence, especially in thicker tumours. In addition, neck metastasis is rare in early stage lower lip squamous cell carcinoma. A ‘wait and see’ policy might be preferred in early stage T1 lower lip squamous cell carcinoma cases.

High azathioprine dose and lip cancer risk in liver, heart, and lung transplant recipients: A population-based cohort study

BACKGROUND

Iatrogenic immunosuppression is a risk factor for lip cancer but the determinants are unknown.

OBJECTIVE

We sought to quantify the association between the type, dose, and duration of iatrogenic immunosuppression and lip cancer risk in solid organ transplant recipients.

METHODS

We conducted a population-based cohort study of all adult Australian liver, heart, and lung transplant recipients from 1984 to 2006 (n = 4141). We abstracted longitudinal data from medical records and ascertained incident lip cancer (n = 58) and deaths (n = 1434) by linkage with national registries. We estimated multivariable hazard ratios (HR) for lip cancer using the Fine and Gray proportional subdistribution hazards model, accounting for death as a competing risk.

RESULTS

Lip cancer risk (n = 58) increased with high mean daily dose of azathioprine (HR 2.28, 95% confidence interval [CI] 1.18-4.38), longer duration of immunosuppression (HR 9.86, 95% CI 2.10-46.3), increasing year of age at transplantation (HR 1.14, 95% CI 1.04-1.25), earlier transplantation era (HR 8.73, 95% CI 1.11-68.7), and history of smoking (HR 2.71, 95% CI 1.09-6.70).

LIMITATIONS

Data on potential confounders such as personal solar ultraviolet radiation exposure were not available.

CONCLUSION

Higher doses of azathioprine increase lip cancer risk, with implications for managing immunosuppressed populations and our understanding of the relationship between solar ultraviolet radiation and lip cancer.

The pattern of lip cancer occurrence over the 1990-2011 period in public hospitals in Madrid, Spain

BACKGROUND

Some regions of Spain along with Canada and Australia have the highest rates of lip cancer in the world. The objective of this study was to examine the trends in the pattern of occurrence of lip cancer in Madrid, Spain.

METHODS

Data were extracted from the Central Tumour Registry of Madrid, between 1990 and 2011. Variables examined were age, sex, topographic and morphological location and tumour histology. Two consecutive periods, 1990-2001 and 2002-2011, were studied by descriptive and analytical methods, and the data from the two periods were statistically compared.

RESULTS

A total of 881 cases were registered during the period 1990-2011. Comparing data between the two periods (1990-2001 and 2002-2011), subtle variations in age, histology and location were noted. Gender ratios remained constant. The mean age increased from 66.3 to 69.7 years (P < 0.05). In the second period, the histological distribution showed an increase in frequency of basal cell carcinoma, from 2.1% to 4.7%, while the frequency of squamous cell carcinomas remained constant. Basal cell carcinoma no longer predominantly occurred in women, decreasing from 80% to 21.1% (P < 0.001). The distribution by gender of squamous cell carcinoma had become more equal due an increase in its frequency in women (P < 0.001). Frequency of tumours on lip mucosa and commissure had increased between the two periods (P < 0.004).

CONCLUSIONS

The pattern of lip cancer reported to Public Hospitals of Madrid is changing: declining rates are noted since 2001-02. However, it is necessary to monitor these data to confirm the observed trends in future years.

[Specific 5-year oral cancer survival and associated factors in cancer outpatients in the Brazilian Unified National Health System]

This study aimed to analyze the specific five-year oral cancer survival rate and associated factors in Brazil. This was a retrospective cohort study using the Oncological Database as the source, with probabilistic-deterministic linkage of all the records for authorization of radiotherapy and/or chemotherapy in the Unified National Health System from 2000 to 2006, generating a single record for each patient. The current study included patients diagnosed with oral cancer from 2002 to 2003 (except for cancer of lip), and ranging from 19 to 100 years of age (N = 6,180). Specific five-year survival was 60%. Decreased specific survival was associated with: age > 40 years; stages III or IV; location on the tongue, floor of the mouth, or base of the tongue; not performing surgical treatment, performing only chemotherapy or radiotherapy and chemotherapy; and residence in certain States of Brazil. The results emphasize the need to include assessment of regional disparities as a possibility for increasing health interventions and improving survival.

Disparities in knowledge of mouth or throat cancer among rural Floridians

OBJECTIVE

The aim of this study was to examine risk factors for reduced mouth or throat cancer (MTC) knowledge using a sample of rural North Floridian adults.

METHODS

Telephone interviews were conducted across rural census tracts throughout North Florida in 2009-2010, using a survey adapted for cultural appropriateness. The sample consisted of 2,393 individuals (1,059 males and 1,334 females; 1,681 whites and 712 blacks).

FINDINGS

Only 9% of the study respondents indicated they had not heard of MTC; however, only 12% endorsed knowing "a lot." Higher education levels and health literacy indicated they had more MTC knowledge. Among female participants, whites had more knowledge than blacks (OR = 1.9). Among black participants, males had more knowledge than females (OR = 1.7). Conversely, greater concern with MTC was associated with lower education levels, health literacy, and financial status, but higher depression scores. Awareness that excessive sun exposure is a risk factor for MTC was lower than for earlier studies using more urban samples.

CONCLUSIONS

This study adds to the literature on MTC knowledge and concern because this sample was drawn exclusively from rural populations in North Florida, a group with the highest MTC morbidity and mortality. An unanticipated finding was that blacks were more concerned than their white rural counterparts. This study was also the first to report that depression was associated with increased concern about MTC. The goal is to persuade at-risk groups to obtain MTC screenings with the goal of reducing disparities in MTC whenever they occur.

Patterns and timing of sunlight exposure and risk of basal cell and squamous cell carcinomas of the skin--a case-control study

BACKGROUND

Non-melanoma skin cancer (NMSC), comprised of basal (BCC) and squamous (SCC) cell carcinomas, is the most common cancer in Caucasians. Ultraviolet radiation (UVR) exposure is the most important environmental risk factor for NMSC. However, the precise relationship between UVR and the risk of NMSC is complex, and the relationship may differ by skin cancer type.

METHODS

A case-control study was conducted among Florida residents to investigate measures of patterns (intermittent vs. continuous) and timing (childhood vs. adulthood) of sunlight exposure in BCC and SCC. Participants included 218 BCC and 169 SCC cases recruited from a university dermatology clinic and 316 controls with no history of skin or other cancers.

RESULTS

A history of blistering sunburn (a measure of intermittent sunlight exposure) was associated with both BCC (OR = 1.96, 95% CI = 1.27-3.03) and SCC (OR = 2.02, 95% CI = 1.22-3.33). Additionally, having a job in the sun for ≥ 3 months for 10 years or longer (a measure of continuous sunlight exposure) was also associated with both BCC and SCC in our study population. With the exception of younger age at first blistering sunburn, measures of younger age at sunlight exposure tended to be associated with SCC, but not BCC risk.

CONCLUSIONS

Results from the current study suggest that sunlight exposure is associated with both BCC and SCC risk regardless of the pattern in which the exposure was received (i.e. intermittent vs. continuous). The data also suggest that sunlight exposure at a younger age may be more important for SCC but not BCC, however additional studies are needed to further characterize sunlight exposure-response relationships in different types of NMSC.

The prevalence of actinic cheilitis in farmers in a semi-arid northeastern region of Brazil

BACKGROUND

Actinic cheilitis (AC) is a potentially malignant disorder of the lip caused by chronic exposure to solar radiation. Despite being a relatively common lesion in tropical countries, the data related to AC prevalence in Brazil are sparse, particularly in regions with high levels of ultraviolet radiation.

OBJECTIVE

To estimate AC prevalence among farmers in a semiarid northeastern Brazil.

METHODS

Cross-sectional study was carried out involving a representative sample (n = 240) of the farm workers. Sociodemographic, clinical, and histopathological variables were analyzed.

RESULTS

AC prevalence was 16.7% [95% confidence interval (CI): 12.0% to 21.4%]. The disease was more prevalent in males [prevalence ratio (PR) = 2.72; 95% CI: 1.52-4.90], fair-skinned farmers (PR = 2.07; 95% CI: 1.00-4.30), age over 50 years (PR = 2.91; 95% CI: 1.40-6.04), daily exposure time more than eight hours (PR = 1.84; 95% CI: 1.03-3.27), and among smokers/ex-smokers (PR = 2.17; 95% CI: 1.22-3.87). Mantel-Haenszel test showed a positive relationship between cumulative exposure time and development of AC (P < 0.001). Two cases were diagnosed as microinvasive squamous cell carcinoma.

CONCLUSIONS

Our results suggest that farmers in this semiarid area have a high risk of lip cancer and indicate the need for health public programs in the early detection of AC and education to teach the population about precautions to be taken during sun exposure.

Emerging strategies for the early detection and prevention of head and neck squamous cell cancer

Despite significant improvements in therapeutic protocols, head and neck squamous cell carcinoma (HNSCC) remains a major health problem worldwide. The 5-year post-therapeutic survival rate is among the lowest of the major cancers with loco-regional relapse being the main cause of death. Moreover, in most instances, the quality of life of the afflicted patient is severely compromised. The poor prognosis for HNSCC is primarily due to disease detection at advanced stages. Accordingly, development of early detection and preventive strategies are essential. Recent advances in our understanding of the molecular biology and etiology of HNSCC should facilitate development of improved intervention and therapeutic approaches. The present review discusses the potential role of such factors for developing preventive and early diagnostic strategies for HNSCC management.

Lifestyle factors of smoking, BMI and alcohol on the risk of Non-Melanoma Skin Cancer in adults: a systematic review

BACKGROUND

Non-melanoma skin cancer is the most common cancer in humans and the most important risk factors are thought to be age, skin type, and exposure to ultraviolet radiation. Lifestyle factors may also play a part. To date no systematic review has been performed to collate evidence of the effects of smoking, alcohol or body mass index.

OBJECTIVES

We performed a systematic review and meta-analysis to assess the effects of smoking, alcohol and body mass index on the risk of non-melanoma skin cancer and its subtypes.

INCLUSION CRITERIA

Adults (18+ years old) of either sex from any ethnicitySmoking, alcohol, or body mass index (including other anthropometric measurements, such as weight, waist to hip ratio, and the percentage body fat)Non-melanoma skin cancer, cutaneous squamous cell carcinoma, or basal cell carcinomaComparative observational epidemiological studies SEARCH STRATEGY: We performed a comprehensive search of MEDLINE, EMBASE, CINAHL, Cochrane Library and CAB Abstracts from inception to October 2010. We also scanned reference lists to identify further eligible studies.

METHODOLOGICAL QUALITY

Data from eligible studies were extracted and quality assessed using the Newcastle Ottawa Scale independently by two reviewers.

DATA COLLECTION

The titles, abstracts and full text identified from the search were assessed independently by two reviewers against pre-specified inclusion/exclusion criteria. Disagreements were resolved through discussion with a third reviewer.

DATA SYNTHESIS

For studies with similar exposures, a meta-analysis was performed using a random effects model and results were expressed as pooled odds ratio with 95% confidence intervals. Heterogeneity was assessed using I. Publication bias was assessed using funnel plots. Data were analysed using Review Manager.

RESULTS

Thirty studies were included of which 22 used a case control design and the remaining used a cohort design. The overall quality of the studies was variable with a Newcastle Ottawa Scale median score of 6 out of 9 stars. No evidence of asymmetry was detected in the funnel plots. Smoking was not significantly related to increased risks of non-melanoma skin cancer (Odds Ratio 0.62, 95% CI 0.21 to 1.79, I=34%, 2 studies) or basal cell carcinoma (Odds Ratio 0.95, 95% CI 0.82 to 1.09; I=59%, 14 studies). However, smoking was significantly associated with a 52% increase in the risk of cutaneous squamous cell carcinoma (95% CI 1.15 to 2.01; I=64%; 6 studies). Subgroup analysis found no significant difference in results based on the definition of smoking (current, former, or ever smoker) for basal cell carcinoma, cutaneous squamous cell carcinoma or non-melanoma skin cancer. Alcohol was not significantly related to increased risks of non-melanoma skin cancer (1 study), basal cell carcinoma (Odds Ratio 1.03, 95% CI 0.94 to 1.13, I=0%, 9 studies) or cutaneous squamous cell carcinoma (1 study). Similar results were found irrespective of the type of alcohol assessed (beer, wine, or spirits) for basal cell carcinoma and cutaneous squamous cell carcinoma. A pooled analysis of five studies found a non-significant decrease in the risk of basal cell carcinoma associated with a higher body mass index (Odds Ratio 0.94, 95% CI 0.84 to 1.04, I=40%). In a subgroup analysis based on sex, the potential reduction in risk of basal cell carcinoma appeared to be confined to males (Males: Odds Ratio 0.90, 95% CI 0.78 to 1.04, I=45%, 4 studies; Females: Odds Ratio 1.01, 95% CI 0.85 to 1.19, I=14%, 3 studies).

CONCLUSION

It is unclear at present if smoking modifies the risk of basal cell carcinoma; however, smoking clearly increases the risk of cutaneous squamous cell carcinoma. Limited evidence has been published about the risk of non-melanoma skin cancer with alcohol and body mass index; however there is some suggestion a high body mass index may be slightly protective of basal cell carcinoma, particularly in males.This study highlights the importance for clinicians to actively survey high risk patients, including current smokers.The majority of studies included in this systematic review assessed the associations between basal cell carcinoma and smoking, alcohol or body mass index. However, more evidence is needed before conclusive recommendations can be formed regarding the relationship between cutaneous squamous cell carcinoma and alcohol or body mass index.

Lip cancer: retrospective analysis of 181 cases

BACKGROUND

In Germany little data on the epidemiology and histology of lip cancers are available, as lip cancers are commonly pooled together with head and neck tumors.

PATIENTS AND METHODS

Retrospective analysis of 181 patients with malignant tumors of the lips with respect to gender, location, histology, risk factors and comorbidity.

RESULTS

There were 90 women and 91 men with a mean age of 71 years. 98 had a tumor on the upper lip and 83 patients on the lower lip. Tumors of the upper lip showed a slight female preference (61%). In contrast lower lip cancer was more common (64%) in men. Histological analysis revealed that in both regions nodular basal cell carcinomas as well as squamous cell carcinomas (NOS) are the most common subtypes. Vertical tumor thickness of squamous cell carcinomas was in most cases smaller than 6 mm (n = 71) and only in 4 cases was a tumor thickness of >6 mm detected. Altogether, 57% of the patients reported a high to very high sun exposure.

CONCLUSIONS

In comparison to previous studies we found a weaker preference for women for tumors of the upper lip and also a weaker preference for men for tumors of the lower lip. The causes remain unclear, but could be causally related to an increased life expectancy and/or changed risk profile.

Case-control study of smoking and non-melanoma skin cancer

OBJECTIVE

To investigate the association between cigarette smoking and basal and squamous cell carcinomas (BCC and SCC) of the skin, a clinic-based case-control study was conducted in Tampa, FL.

METHODS

Patients with histologically confirmed BCC/SCC were recruited from a university dermatology clinic (n = 215 BCC, 165 SCC). Controls were comprised of individuals with no history of skin cancer who screened negative for skin cancer upon physical examination at the affiliated cancer screening or primary care clinics (n = 315). Information on smoking and other risk factors was obtained from self-administered questionnaires.

RESULTS

After adjustment for age, sex, and other skin cancer-risk factors, ever smoking was not associated with BCC (odds ratio (OR) = 1.26, 95% confidence interval (CI) = 0.83-1.92), but was statistically significantly associated with SCC (OR = 1.97, 95% CI = 1.19-3.26), with significant trends observed for SCC associated with increasing cigarettes per day (p = 0.01) and pack-years smoked (p = 0.01). Among men, smoking ≥20 pack-years was associated with non-significant increased risks of BCC (OR = 1.90, 95% CI = 0.88-4.12) and SCC (OR = 1.97, 95% CI = 0.84-4.66), whereas among women, no association was observed with BCC (OR = 0.98, 95% CI = 0.39-2.46) while a statistically significant three-fold risk was observed with SCC (OR = 3.00, 95% CI = 1.02-8.80).

CONCLUSION

Cigarette smoking is more strongly associated with SCC than BCC, particularly among women.

Tobacco smoking and cutaneous squamous cell carcinoma: a 16-year longitudinal population-based study

BACKGROUND

Although tobacco smoking is commonly cited as a risk factor for cutaneous squamous cell carcinoma (SCC), the evidence from previous clinical and case-control studies is conflicting. We therefore aimed to prospectively examine the role of tobacco smoking in the development of SCC of the skin in a population-based study.

METHODS

Study participants were 1,287 adults aged 25 to 75 years in 1992, randomly selected from the Nambour community, with no previous history of SCC. Standard skin pigment and sun-sensitivity profiles were obtained at baseline. Detailed prospective information on sun exposure, smoking, and skin cancer occurrence (histologically confirmed) was collected over a 16-year period, 1992 to 2007.

RESULTS

Of 1,287 participants, 43% were male and average age was 48 years. A total of 188 first cutaneous SCCs were identified during the study period. After adjustment for other known risk factors, neither former nor current smokers were at raised risk of SCC: relative risk (RR) = 1.1, 95% CI: 0.8-1.5 and RR = 1.1, 95% CI: 0.7-1.5, respectively, compared with lifelong nonsmokers, nor were there any dose-response relationships with amount smoked or duration of smoking and risk of SCC.

CONCLUSIONS

In this Australian follow-up study, tobacco smoking did not increase the risk of SCC of the skin.

IMPACT

These prospective adjusted data provide strong evidence which suggests that cutaneous SCC should not be on the list of tobacco-related cancers.

Lip cancer: incidence, trends, histology and survival: 1970-2006

BACKGROUND

High levels of lip cancer have been reported among Israelis over the last four decades. Epidemiological descriptions and analyses for this region have not previously been presented.

OBJECTIVES

To establish the incidence, trends and histology of lip cancer and associated demographic variables in Israel over time.

METHODS

Data for 1970-2006 were derived from the Israel National Cancer Registry. Incidence and trends over time and analyses by lip site, sex, age, origin, histology and 5-year survival were studied.

RESULTS

Of 4337 new cases, most were found among men (61.4%), people aged over 53 years (75.5%), and those with lighter skin (62.6%). Lip cancer cases were 40 times more prevalent in the external than in the inner lip. The dominant tumour type was squamous cell carcinoma at the external lower lip and intraoral lip mucosa (predominantly in men) and basal cell carcinoma (originating from skin) at the external upper lip (predominantly in women). Minor salivary gland tumours, melanoma and metastases were also reported. Slight increases in the trend of upper lip cancer and decreases for lower lip cancer were reported.

CONCLUSIONS

Men, fair-skinned individuals and those over 53 years of age were at higher risk for lip cancer. A higher incidence of external lip cancer, compared with internal, may indicate a major role for sun exposure rather than smoking. The effect of public awareness campaigns as well as occupational changes, both related to sun exposure, should be studied carefully as potential factors in the changing incidence of lip tumours.

UVR exposure sensitizes keratinocytes to DNA adduct formation

UV radiation (UVR) and exposure to tobacco smoke, a source of polycyclic aromatic hydrocarbons (PAH), have been linked to skin carcinogenesis. UVR-mediated activation of the aryl hydrocarbon receptor (AhR) stimulates the transcription of CYP1A1 and CYP1B1, which encode proteins that convert PAH to genotoxic metabolites. We determined whether UVR exposure sensitized human keratinocytes to PAH-induced DNA adduct formation. UVR exposure induced CYP1A1 and CYP1B1 in HaCaT cells, an effect that was mimicked by photooxidized tryptophan (aTRP) and FICZ, a component of aTRP. UVR exposure or pretreatment with aTRP or FICZ also sensitized cells to benzo(a)pyrene (B[a]P)-induced DNA adduct formation. alphaNF, an AhR antagonist, suppressed UVR-, aTRP-, and FICZ-mediated induction of CYP1A1 and CYP1B1 and inhibited B[a]P-induced DNA adduct formation. Treatment with 17-AAG, an Hsp90 inhibitor, caused a marked decrease in levels of AhR; inhibited UVR-, aTRP-, and FICZ-mediated induction of CYP1A1 and CYP1B1; and blocked the sensitization of HaCaT cells to B[a]P-induced DNA adduct formation. FICZ has been suggested to be a physiologic ligand of the AhR that may have systemic effects. Hence, studies of FICZ were also carried out in MSK-Leuk1 cells, a model of oral leukoplakia. Pretreatment with alpha-naphthoflavone or 17-AAG blocked FICZ-mediated induction of CYP1A1 and CYP1B1, and suppressed the increased B[a]P-induced DNA adduct formation. Collectively, these results suggest that sunlight may activate AhR signaling and thereby sensitize cells to PAH-mediated DNA adduct formation. Antagonists of AhR signaling may have a role in the chemoprevention of photocarcinogenesis.

A review of risk factors and genetic alterations in head and neck carcinogenesis and implications for current and future approaches to treatment

Head and neck cancer is the fifth most common cancer worldwide but the most common malignant disease site in central Asia. The treatment of head and neck cancer is one of the most challenging in clinical oncology because of the high content of hypoxic cells of the cancer which increases resistance to therapy and also because of the high capacity of the cancer to regrow during treatment. For unresectable tumours, radiotherapy and chemotherapy alone or more often in combination is the treatment of choice. The aim of this paper is to review current understanding of carcinogenesis of head and neck cancer in relation to predisposing risk factors in general and for specific sub-sites and how these risk factors interact with the main reported genetic alterations in the progression of the cancer. The implications of these changes in determining choice of therapy are also discussed from a brief historical perspective of the various treatment approaches of head and neck cancer.