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Screening for syphilis in patients with carcinoma of the tongue
Brirish Journal of Oral and A4axi//ofacia/ Surgery (1995) 33, 319-320 0 1995 The British Association of Oral and Maxillofacial Surgeons
I
I
Screening for syphilis in patients with carcinoma of the tongue A. J. Dickenson, W. J. R. Currie, B. S. Avery Department
of Maxillofacial
Surgery, Middlesbrough
General Hospital, Middlesbrough,
Cleveland
SUMMARY. The oral signs of syphilis have been comprehensively described and can be identified at each stage of the infection. Despite the historical recognition that inadequately treated or untreated syphilitic leukoplakia may undergo malignant transformation, many surgical units no longer routinely screen patients presenting with malignant or premalignant lesions. In this study, five of the 63 patients (8%) who presented with neoplasms of the tongue reacted to syphilis antibodies. These results indicate that syphilis is still prevalent in this group of patients and suggest that serological investigations may be warranted in the initial assessment of all patients with oral cancer.
noma of the tongue were examined retrospectively. With the exception of one case all were over 60 years of age (median 68 years; range 16-81 years). As part of the routine preoperative screening programme, each patient was tested for antibodies to syphilis by the Venereal Disease Research Laboratory test and the Treponema pallidurn haemagglutination assay.
INTRODUCTION
At the turn of the century it was recognised that patients who presented with carcinoma of the tongue had a high incidence of syphilitic infections.’ This association was predominant among men, who were often younger than their uninfected counterparts.’ In that period syphilis was a common sexually transmitted disease.3 During the 1920s and 1930s patients with carcinoma of the tongue were 3-5 times more likely to have syphilis than random samples of general hospital patients. Further work showed that this association was largely confined to patients with carcinoma of the tongue.4 There was a similar but less pronounced pattern for patients with carcinoma of the lip. With the exception of carcinoma of the stomach, the coincidence of syphilis and carcinoma decreased on descending the gastrointestinal tract. Over the years the incidence of syphilis in the general population has declined sharply.5 Previously it was prevalent in the heterosexual community but changing sexual practice and the introduction of effective treatment has resulted in reduced exposure and infection, while the incidence of other sexually transmitted disease, particularly HIV, has increased.(j It is now uncommon to see the oral manifestations of syphilis in the western world. As a result the link between syphilis and carcinoma seems to be becoming a historical curiosity. In this study however, we found a series of patients with no known history of syphilis who when routinely tested reacted to syphilis antibodies.
PATIENTS
RESULTS
Of the 63 patients studied, five subjects (3 male, 2 female) reacted to antibodies by both tests (Table 1). None of these patients gave a history of previous infection with or treatment for syphilis, and there was no evidence implicating other clinical conditions that could have contributed to a false positive result. As the catchment population covered by the hospital is 1 100000, this correlates to an incidence of tongue cancer of 0.95/100000 population year. It is more difficult to assess the true incidence of syphilis in a comparable population because of lack of disclosure and cross-regional distortion of the communicable disease figures. Data obtained from the Communicable Disease Surveillance Committee about the number of new cases of primary and secondary syphilis in England and Wales over the equivalent period ( 1984-90) were analysed. The mean annual number of new cases in the over-45 age group is 1.54/100000. The observed incidence of tongue cancer in patients who reacted to antibodies for syphilis in the Middlesbrough area is 0.075/100000 per year. This is important, because the probability of such a combination occurring randomly in patients in the Middlesbrough area is negligible.
AND METHODS
The case notes of 63 patients who presented to the oral and maxillofacial surgery unit at Middlesbrough General Hospital during a 6-year period (1984-1990) with histologically diagnosed squamous cell carci-
DISCUSSION
Our findings suggest that there is still a small number of patients presenting with carcinoma of the tongue 319
320 Table
British
1 - Tumour
Case no.
1 2 3 4 5
Journal
of Oral
staging
and Maxillofacial
(TNM
Sex
Male Male Male Female Female
classification)
Surgery and reaction
to syphilis
Age (years)
Tumour
61 64 II 70 81
TZNOMO T2NOMO T3NlMO TZNOMO T2NOMO
who react to antibodies for syphilis. This is in contrast to a previous report that the prevalence of syphilitic infection in patients with oral cancer7 is small, but is not as pronounced as the estimate of Trieger et al. of 17.6’%~~Although it is unlikely that such patients will transmit infection to health care workers, it may be necessary to treat the patient for syphilis to prevent the development of late complications of the disease. In our unit we use the Venereal Disease Research Laboratory and T. pallidurn haemaglutination assay for screening patients for syphilis. These tests are inexpensive and reliable.’ As with all procedures, there is the possibility of producing technical or biological false-positive results. Technical errors can occur if there is lack of care when processing the venous sample or incorrect labelling of the sample. Biological false-positive results occur in patients with other spirochaetal infections such as yaws, endemic (non-venereal) syphilis, and pinta. A false positive Venereal Disease Research Laboratory result can occur during infectious mononucleosis, hepatitis, tuberculosis, or systemic lupus erythematosus, but these errors can be reduced by taking an adequate medical history. It would be unwise to attempt to define a causal association between squamous cell carcinoma of the oral cavity and syphilis from the results of this small study. This has always been a controversial issue, despite the historical reputation of syphilitic glossitis for undergoing malignant transformation. These results do, however, serve as a timely reminder that patients with cancer of the tongue may occasionally react to syphilis antibodies. Routine serological testing of all patients presenting with malignant or premalignant lesions of the oral cavity should be considered, as detection of unsuspected disease will permit the immediate treatment of syphilis.
antibodies
on admission
Venereal Disease Laboratory test
Research
+ + + + +
Consultant in Communicable Regional Health Authority for
test
+ + + + +
References 1. Singer C. A study of some factors in the aetiology of oral carcinoma. Q J Med 1911; 5: 15-57. 2. Taylor GW. Cancer of the mouth in women. N Engl J Med 1934; 210: 1102-1105. 3. Lund CL. Syphilis in relation to cancer of the buccal mucosa. N Engl J Med 1933; 209: 131-134. 4. Fry HJB. Syphilis and malignant disease. Journal of Hygiene 1929; 29: 313-14. 5. Binnie WH, Rankin KV, Mackenzie IC. Aetiology of oral squamous cell carcinoma. J Oral Path01 1983; 12: 1 l-29. 6. Kinghorn A. The re-emergence of syphilis. Br J Hosp Med 1993; 49( 10): 683-685. 7. Scully C, Prime SS, Cox MF, Maitland NJ. in Risk Markers in Oral Disease Vol. 2. Johnson N ed. Cambridge: Cambridge University Press, 1991: 966113. 8. Trieger N, Ship II, Taylor GW, Weisberger D. Cirrhosis and other predisposing factors in carcinoma of the tongue. Cancer 1958; 11: 357-362. 9. Thin RN, Barlow D. Syphilis. Medicine International 1993; 21: 121-125.
The Authors A. J. Dickenson BCbD, FDS Senior House Officer W. J. R. Currie FDSRCS Medical Student Glasgow University Glasgow B. S. Avery FDSRCS, FRCS Consultant Oral and Maxillofacial Surgeon Department of Maxillofacial Surgery Middlesbrough General Hospital Ayresome Green Lane Middlesbrough T55 5AZ Cleveland
Correspondence and requests for offprints to Andrew Dickenson, 77 Emerson Avenue, Linthorpe, Middlesbrough, Cleveland TS5 745.
Acknowledgements We thank Dr Nicol M. I. Black, Disease Control for the Northern supplying the figures.
T pallidurn haemagglutination
Paper received 4 November Accepted 13 July 1994
1993
I
I
Screening for syphilis in patients with carcinoma of the tongue A. J. Dickenson, W. J. R. Currie, B. S. Avery Department
of Maxillofacial
Surgery, Middlesbrough
General Hospital, Middlesbrough,
Cleveland
SUMMARY. The oral signs of syphilis have been comprehensively described and can be identified at each stage of the infection. Despite the historical recognition that inadequately treated or untreated syphilitic leukoplakia may undergo malignant transformation, many surgical units no longer routinely screen patients presenting with malignant or premalignant lesions. In this study, five of the 63 patients (8%) who presented with neoplasms of the tongue reacted to syphilis antibodies. These results indicate that syphilis is still prevalent in this group of patients and suggest that serological investigations may be warranted in the initial assessment of all patients with oral cancer.
noma of the tongue were examined retrospectively. With the exception of one case all were over 60 years of age (median 68 years; range 16-81 years). As part of the routine preoperative screening programme, each patient was tested for antibodies to syphilis by the Venereal Disease Research Laboratory test and the Treponema pallidurn haemagglutination assay.
INTRODUCTION
At the turn of the century it was recognised that patients who presented with carcinoma of the tongue had a high incidence of syphilitic infections.’ This association was predominant among men, who were often younger than their uninfected counterparts.’ In that period syphilis was a common sexually transmitted disease.3 During the 1920s and 1930s patients with carcinoma of the tongue were 3-5 times more likely to have syphilis than random samples of general hospital patients. Further work showed that this association was largely confined to patients with carcinoma of the tongue.4 There was a similar but less pronounced pattern for patients with carcinoma of the lip. With the exception of carcinoma of the stomach, the coincidence of syphilis and carcinoma decreased on descending the gastrointestinal tract. Over the years the incidence of syphilis in the general population has declined sharply.5 Previously it was prevalent in the heterosexual community but changing sexual practice and the introduction of effective treatment has resulted in reduced exposure and infection, while the incidence of other sexually transmitted disease, particularly HIV, has increased.(j It is now uncommon to see the oral manifestations of syphilis in the western world. As a result the link between syphilis and carcinoma seems to be becoming a historical curiosity. In this study however, we found a series of patients with no known history of syphilis who when routinely tested reacted to syphilis antibodies.
PATIENTS
RESULTS
Of the 63 patients studied, five subjects (3 male, 2 female) reacted to antibodies by both tests (Table 1). None of these patients gave a history of previous infection with or treatment for syphilis, and there was no evidence implicating other clinical conditions that could have contributed to a false positive result. As the catchment population covered by the hospital is 1 100000, this correlates to an incidence of tongue cancer of 0.95/100000 population year. It is more difficult to assess the true incidence of syphilis in a comparable population because of lack of disclosure and cross-regional distortion of the communicable disease figures. Data obtained from the Communicable Disease Surveillance Committee about the number of new cases of primary and secondary syphilis in England and Wales over the equivalent period ( 1984-90) were analysed. The mean annual number of new cases in the over-45 age group is 1.54/100000. The observed incidence of tongue cancer in patients who reacted to antibodies for syphilis in the Middlesbrough area is 0.075/100000 per year. This is important, because the probability of such a combination occurring randomly in patients in the Middlesbrough area is negligible.
AND METHODS
The case notes of 63 patients who presented to the oral and maxillofacial surgery unit at Middlesbrough General Hospital during a 6-year period (1984-1990) with histologically diagnosed squamous cell carci-
DISCUSSION
Our findings suggest that there is still a small number of patients presenting with carcinoma of the tongue 319
320 Table
British
1 - Tumour
Case no.
1 2 3 4 5
Journal
of Oral
staging
and Maxillofacial
(TNM
Sex
Male Male Male Female Female
classification)
Surgery and reaction
to syphilis
Age (years)
Tumour
61 64 II 70 81
TZNOMO T2NOMO T3NlMO TZNOMO T2NOMO
who react to antibodies for syphilis. This is in contrast to a previous report that the prevalence of syphilitic infection in patients with oral cancer7 is small, but is not as pronounced as the estimate of Trieger et al. of 17.6’%~~Although it is unlikely that such patients will transmit infection to health care workers, it may be necessary to treat the patient for syphilis to prevent the development of late complications of the disease. In our unit we use the Venereal Disease Research Laboratory and T. pallidurn haemaglutination assay for screening patients for syphilis. These tests are inexpensive and reliable.’ As with all procedures, there is the possibility of producing technical or biological false-positive results. Technical errors can occur if there is lack of care when processing the venous sample or incorrect labelling of the sample. Biological false-positive results occur in patients with other spirochaetal infections such as yaws, endemic (non-venereal) syphilis, and pinta. A false positive Venereal Disease Research Laboratory result can occur during infectious mononucleosis, hepatitis, tuberculosis, or systemic lupus erythematosus, but these errors can be reduced by taking an adequate medical history. It would be unwise to attempt to define a causal association between squamous cell carcinoma of the oral cavity and syphilis from the results of this small study. This has always been a controversial issue, despite the historical reputation of syphilitic glossitis for undergoing malignant transformation. These results do, however, serve as a timely reminder that patients with cancer of the tongue may occasionally react to syphilis antibodies. Routine serological testing of all patients presenting with malignant or premalignant lesions of the oral cavity should be considered, as detection of unsuspected disease will permit the immediate treatment of syphilis.
antibodies
on admission
Venereal Disease Laboratory test
Research
+ + + + +
Consultant in Communicable Regional Health Authority for
test
+ + + + +
References 1. Singer C. A study of some factors in the aetiology of oral carcinoma. Q J Med 1911; 5: 15-57. 2. Taylor GW. Cancer of the mouth in women. N Engl J Med 1934; 210: 1102-1105. 3. Lund CL. Syphilis in relation to cancer of the buccal mucosa. N Engl J Med 1933; 209: 131-134. 4. Fry HJB. Syphilis and malignant disease. Journal of Hygiene 1929; 29: 313-14. 5. Binnie WH, Rankin KV, Mackenzie IC. Aetiology of oral squamous cell carcinoma. J Oral Path01 1983; 12: 1 l-29. 6. Kinghorn A. The re-emergence of syphilis. Br J Hosp Med 1993; 49( 10): 683-685. 7. Scully C, Prime SS, Cox MF, Maitland NJ. in Risk Markers in Oral Disease Vol. 2. Johnson N ed. Cambridge: Cambridge University Press, 1991: 966113. 8. Trieger N, Ship II, Taylor GW, Weisberger D. Cirrhosis and other predisposing factors in carcinoma of the tongue. Cancer 1958; 11: 357-362. 9. Thin RN, Barlow D. Syphilis. Medicine International 1993; 21: 121-125.
The Authors A. J. Dickenson BCbD, FDS Senior House Officer W. J. R. Currie FDSRCS Medical Student Glasgow University Glasgow B. S. Avery FDSRCS, FRCS Consultant Oral and Maxillofacial Surgeon Department of Maxillofacial Surgery Middlesbrough General Hospital Ayresome Green Lane Middlesbrough T55 5AZ Cleveland
Correspondence and requests for offprints to Andrew Dickenson, 77 Emerson Avenue, Linthorpe, Middlesbrough, Cleveland TS5 745.
Acknowledgements We thank Dr Nicol M. I. Black, Disease Control for the Northern supplying the figures.
T pallidurn haemagglutination
Paper received 4 November Accepted 13 July 1994
1993