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ORIGINAL ARTICLE Head and Neck Cancers
Squamous cell carcinoma of upper alveolus: An experience of a tertiary care
center of Northeast India
Nizara Baishya,Tashnin Rahman, Ashok Kumar Das, Chandi Ram Kalita1, Jagannath Dev Sharma2,
Manigreeva Krishnatreya3, Amal Chandra Kataki4

Abstract
Objective: The main objective of this study was to analyze the clinical behavior and the impact of nodal metastasis on the prognosis of upper alveolus
squamous cell carcinoma (SCC). Materials and Methods: The medical records of 110 patients with SCC of the upper alveolus (International Classification
of Diseases‑10‑C03.0) diagnosed during 2010–2015 were reviewed. Survival analysis was done using the Kaplan–Meier method and was compared using
log rank‑test. P < 0.05 was considered statistically significant. Results: Of the 110 patients, 59 were males and 51 were females. Forty‑six (41.8%) patients
presented with lymph node metastasis. Fifty‑three (51.8%) patients presented in Stage IVA, thirty (27.3%) patients in Stage IVB, ten (9.1%) patients in Stage III,
12 (10.9%) patients in Stage II.The 5‑year overall survival (OS) was 71.1% in Stage II, in Stage III it was 65.6%, in Stage it was IVA 56.7%, and in Stage IVB it was
19.4% (P = 0.02). The 5‑year OS for node negative compared with node positive was 66.3% versus 37.3%, respectively (P = 0.019). Conclusion: Presence
of lymph node metastasis is associated with lower survival rates. Adequate surgical resection with adjuvant treatment, where necessary, offers the best
chance of disease control.
Key words: Aggressive, cancer, neck node, prognosis, upper alveolus

Introduction were diagnosed in the study period. Each patient’s medical

Head‑and‑neck cancers (HNCs) are the sixth most common records were reviewed for clinical and demographic parameters.
malignancy worldwide. Approximately, half of the reported Staging was performed according to the criteria for OC developed
head and neck malignancies are oral cavity squamous cell by the American Joint Committee on Cancer 7th Edition.
carcinomas (SCCs), with an estimated 300,000 new cases Inclusion criteria
every year globally.[1] Oral cancer (OC) is a common cancer 1. Previously untreated patients
in the Southeast Asia region. According to the National Cancer 2. Histologically proven SCC
Registry Programme of India, among males, Ahmedabad 3. Tumours confined to upper alveolus and UGBC.
Urban Cancer Registry and East Khasi Hills Cancer Registry
in females have recorded the highest age‑adjusted incidence Exclusion criteria
rates of OC.[2] This higher prevalence of OC may be attributed 1. Patients with tumors extending to the upper alveolus from
to the high consumption of areca nut and tobacco in any form adjacent areas (e.g., tonsil, soft palate) were excluded
in these regions. Because of the close proximity of the upper 2. Synchronous primary tumours
alveolar (ridge) mucosa with the upper gingivo‑buccal sulcus or 3. Patients who did not underwent treatment.
the upper part of the buccal mucosa, cancer of the upper alveolus
may spread to these adjacent sites and thus making it difficult to Patients were followed up by hospital revisit records, telephonic
localize the exact origin of the disease.[3] Upper gingival cancers calls, and home visits. All patients were followed up for at least
accounted for only 3.5% of all OCs.[4] SCC of the oral cavity has 5 years. Data were analyzed using Statistical Package for Social
a predilection for regional lymph node metastasis. However, only Sciences (SPSS 19.0, IBM Inc., Chicago, IL, USA). Kaplan–Meir
few studies have been conducted regarding the regional metastasis method was used for survival analysis and was compared using
of SCC upper alveolus.[5] Upper gingival–buccal cancers (UGBCs) log rank‑test. P < 0.05 was considered statistically significant.
are biologically more aggressive than lower gingival–buccal Results
cancers, which have a comparatively better disease‑free survival
One hundred and ten patients with SCC of the upper alveolus
even in advanced stages.[6] The aggressive behavior is possibly
were included in the present study. Of the 110 patients’ cohort, 59
because of late presentation of UGBC and early invasion of the
were males and 51 were females (male:female ratio was 1.16:1).
infratemporal fossa.[3] We herein present our 6‑year experience of
The median age of presentation was 55 years, with a range from
treating upper alveolus at a tertiary care cancer center.
32 to 80 years. Thirty‑two (29.1%) patients were below 50 years
Materials and Methods and 78 (70.9%) were 50 years and above [Table 1].
The study has been approved by the Institutional Ethics Of the 110 patients, 71 (64.5%) patients were diagnosed histologically
Committee of the institute. The study was a retrospective analysis as well‑differentiated SCC (WDSCC), 28 (25.5%) patients with
of patients with SCC upper alveolus (International Classification moderately differentiated SCC (MDSCC), and 11 (10.0%) patients
of Diseases‑10 [ICD‑10]‑C03.0) diagnosed from January 1, 2010 with poorly differentiated SCC (PDSCC) at the time of final
to December 31, 2015, in a tertiary care cancer center in the diagnosis. On clinical and radiological examination, 14 (12.7%)
North East India. A total of 194 patients with SCC upper alveolus tumors were classified as T2, 13 (11.8%) as T3, 53 (48.2%) as T4a,
This is an open access journal, and articles are distributed under the terms of the Creative
Access this article online Departments of Head and Neck Surgery, 1Hospital Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix,
Based Cancer Registry, 2Pathology, 3Cancer Registry tweak, and build upon the work non‑commercially, as long as appropriate credit is given
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Dr. B Borooah Cancer Institute, Guwahati, Assam, India For reprints contact: reprints@medknow.com
Correspondence to: Dr. Nizara Baishya,
E‑mail: nizara.baishya@gmail.com
How to cite this article: Baishya N, Rahman T, Das AK, Kalita CR, Sharma JD,
Website: www.sajc.org
Krishnatreya M, et al. Squamous cell carcinoma of upper alveolus: An experience
DOI: 10.4103/sajc.sajc_66_18 of a tertiary care center of Northeast India. South Asian J Cancer 2019;8:44-6.

44 © 2019 The South Asian Journal of Cancer | Published by Wolters Kluwer ‑ Medknow

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Baishya, et al.: Squamous cell carcinoma of upper alveolus

and 30 (27.3%) as T4b. Forty‑six (41.8%) patients presented with were in Stages III (65.6%), Stage IVA (56.7%), and Stage IVB
cervical lymph nodes metastasis and 64 (58.2%) patients did not (19.4%) (P = 0.02) [Figure 1]. At the 5‑year closing period of
had regional cervical lymph node metastasis. Of the patients with follow‑up, the OS was higher among the patients with node
positive lymph nodes, two were T2‑tumors, eight were T3‑tumors, negative (N‑) than those with node positive (N+) (66.3% versus
19 were T4a‑tumors, and 17 patients had T4b‑tumors (P = 0.019). 37.3%, P = 0.019) [Figure 2]. The median OS in patients with
Furthermore, in tumor grade differentiation of patients with positive N+ was 18 months (95% confidence interval [CI] = 8–28).
lymph nodes, 30 (65.2%) were seen as WDSCC, 12 (26.0%) as Further, OS stratified by tumor grade differentiation is shown
MDSCC, and four (8.6%) as PDSCC. Fifty‑three patients (51.8%) in Figure 3. Five‑year OS was 64.2% in patients with WDSCC,
presented in Stage IVA, thirty (27.3%) patients presented with 32.0% in MDSCC, and 32.8% in PDSCC (P = 0.313).
Stage IVB, ten (9.1%) patients in Stage III, twelve (10.9%) Discussion
patients in Stage II and one patient (0.9%) presented in Stage The alveolar processes of the maxilla and the overlying mucosa
IVC with distant metastasis to the liver. The patients who received covering it constitute the upper alveolar ridge. The mucosal
treatment were categorized as follows: 32 (29.1%) patients received covering of the upper alveolar ridge extends laterally to gingivo–
radiotherapy (RT), 49 (44.5%) patients underwent surgery followed buccal sulcus and then to the buccal mucosa. International
by external beam RT, eight (7.3%) patients were treated by only Classification of Disease (ICD‑10) groups them together as
chemotherapy (CT), 10 (9.1%) underwent surgery followed by C03.0. In oral oncology, the terms “upper alveolus” and “upper
concurrent chemo‑RT (CRT). and five (4.5%) patients underwent only gingiva” have been used more or less synonymously. Morris et al.
surgery. One (0.9%) patient was treated by surgery followed by CT had observed that upper alveolus tumors were more common
as shown in Table 1. in females.[7] However, in our study, it was observed that males
Out of 110 patients, 24 (21.82%) patients were dead at the were more predominantly affected than females. In the West,
closing period of follow‑up and 86 (78.18%) were either alive the mean age of presentation of OC is in the seventh decade.
or censored. The 5‑year overall survival (OS) was higher But in the Indian and South East Asian context, the peak age
among the patients in Stage II (71.1%) compared to those who frequency of OC is a decade earlier, which may be attributed to
the high prevalence of tobacco consumption in our population.
Table 1: Demographic and clinical information of the WDSCC of the upper alveolus was the most common grade of
patients included in the study cohort tumor differentiation (64.5%) in our study. However, this was
Parameters n (%) in contrast to a study done by Pathak et al. where moderately
Gender differentiated variant was the most common type of upper alveolus
Male 59 (53.6)
SCC.[3] Nearly 75.5% of the patients in our study cohort have
Female 51 (46.4)
had T4 disease in contrast to another study by Kumar et al. from
Age group
northern India.[8] It has been observed and well documented that,
<50 32 (29.1)
50 and above 78 (70.9)
the incidence of lymph node metastasis in carcinoma of the tongue
Differentiation and floor of mouth is higher (30%).[9] But, reports on lymph node
WDSCC 71 (64.5) metastasis from SCC upper alveolus is rare. It was seen from our
MDSCC 28 (25.5) study that cervical lymph node metastasis was 41.8% (46/110)
PDSCC 11 (10.0) in patients presenting with upper alveolus SCC. This finding is
T stage much higher than the study done by Li et al. where it was 40%.[10]
T2 14 (12.7) From this study, it can be seen that the chance of nodal metastasis
T3 13 (11.8) increases with increase with the tumor T‑stage (P = 0.019).
T4a 53 (48.2) Treatment approach for oral SCC include single management
T4b 30 (27.3)
Node
N0 64 (58.2)
N+ 46 (41.8)
Composite stage
Stage II 12 (10.9)
Stage III 10 (9.1)
Stage IVA 57 (51.8)
Stage IVB 30 (27.3)
Figure 1: Five‑year overall survival Figure 2: Five‑year overall survival
Stage IVC 1 (0.9) among different stages of cancer between positive and negative nodal
Treatment types metastasis
Surgery 5 (4.5)
Radiotherapy 32 (29.1)
Chemotherapy 8 (7.3)
Surgery + radiotherapy 49 (44.5)
Surgery + chemotherapy 1 (0.9)
Radiotherapy + chemotherapy 5 (4.5
Surgery + radiotherapy + chemotherapy 10 (9.1)
WDSCC=Well differentiated squamous cell carcinoma, MDSCC=Moderately
differentiated squamous cell carcinoma, PDSCC=Poorly differentiated squamous cell
carcinoma Figure 3: Five‑year overall survival among different grades of differentiation
South Asian Journal of Cancer ♦ Volume 8 ♦ Issue 1 ♦ January-March 2019 45
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Baishya, et al.: Squamous cell carcinoma of upper alveolus

with surgery, RT (external beam RT and/or brachytherapy), or Acknowledgment

adjuvant systemic therapy as CT and/or target agents, and with The authors would like to thank the National Centre for
various combination of these modalities depending on the disease Disease Informatics and Research under Indian Council of
presentation and pathological findings.[11] Neo‑adjuvant CT may Medical Research for providing the necessary technical support
be used to downstage the disease in case of borderline operability. to our hospital cancer registry.
In our study, 45% of patients were treated by surgery followed by Financial support and sponsorship
RT, which remained as the single largest treatment modality. Nil.
In our study, the 5‑year OS was higher among the patients in Conflicts of interest
Stage II (71.1%) compared to those who were in Stages III There are no conflicts of interest.
(65.6%), Stage IVA (56.7%) and Stage IVB (19.4%). This
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