Oral Oncology 46 (2010) 834
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Oral Oncology
journal homepage: www.elsevier.com/locate/oraloncology
Letter to the Editor
Criteria to define true second primary oral squamous cell carcinoma
The term ‘‘second primary tumor” (SPT) was proposed to be
allocated for the second tumor that develops independently from
the first tumor. SPTs can present as either synchronous or metach-
ronous lesions. There is a lack of consensus on the duration on
which the lesion would be classified as synchronous or metachro-
nous (Hong et al.1 used 6 or more months and Liao et al.2 used one
month criterion). Such classification appears irrelevant as the
treatment and prognosis depend ultimately on clinical and histo-
pathological prognosticators.
The criteria for SPTs were erroneously attributed to Billroth3 but
Moertel et al.4 revealed that he did not state such unrealistically ri-
gid criteria. Warren and Gates5 established criteria which are widely
used and include: (1) each of the tumors must present a definite pic-
ture of malignancy; (2) each must be distinct; (3) the probability
that one was a metastatic lesion from the other must be excluded.
Histopathological examination often solves the issue of whether
the tumor is malignant, but the other two criteria remain confusing
and debatable. For second criteria there is no agreement in the liter-
ature on what distance should lie between the tumors (Hong et al.1,
Tabor et al.6, and Scholes et al.7 proposed 2 cm, 3 cm, and 1.5 cm,
respectively). We opine that the possibility of undermining of single
OSCC beneath the clinically normal looking mucosa and its presence
at another area (simulating synchronous OSCC) cannot be ignored.
Conversely, it is also possible that two closely associated sites in
case of synchronous/metachronous OSCCs can invade underneath
the normal mucosa towards each other and collide. In both the sit-
uations, malignant epithelial cells will be present beneath the clin-
ically normal oral mucosa. It is impossible to confirm whether OSCC
is synchronous/metachronous or single primary. Hence we propose
that the cases showing presence of malignant epithelial cells be-
neath the normal mucosa should be excluded.
Leong et al.8 added that an SPT should occur at least 3 years
after diagnosis of the primary tumor. With respect to the issue of
discriminating an SPT from a metastasis to the lungs, esophagus,
larynx, a discussion may arise concerning what criteria should be
used: should the time interval between the occurrence of the le-
sions and/or the histologic examination of both the lesions be
the criteria? Thus, because of the subjective decision making, the
clinical definitions of multiplicity carried the risk of misclassifi-
cation. Hence Braakhuis et al.9 described a novel classification of
the secondary tumors on the basis of the molecular analysis of
the tumors and the genetically altered mucosal field in between.
They proposed definitions for a ‘‘true SPT”, a local recurrence, a
‘‘second field tumor” (second field tumor derived from the same
genetically altered mucosal field as the primary tumor), and a
metastasis. Hence, we posit that future studies on SPTs should fol-
low the Braakhuis et al.9 classification as this will increase the
authenticity of the study and help us in better understanding of
the nature and the behavior of the true SPTs.
1368-8375/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.oraloncology.2010.09.006
Conflict of interest statement
None declared.
References
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Sachin C. Sarode
Department of Oral Pathology and Microbiology,
Dr. D.Y. Patil Dental College and Hospital, Maheshnagar, Pimpri,
Pune – 18, Maharashtra, India.
Tel.: +91 9922491465.
E-mail address: drsachinsarode@gmail.com
Gargi S. Sarode
Department of Oral Pathology and Microbiology,
Dr. D.Y. Patil Dental College and Hospital, Maheshnagar, Pimpri,
Pune – 18, Maharashtra, India.
Tel.: +91 9823871462.
E-mail address: gargi14@gmail.com
Anuprita Patil
Department of Oral Pathology and Microbiology,
Dr. D.Y. Patil Dental College and Hospital, Maheshnagar, Pimpri,
Pune – 18, Maharashtra, India.
Tel.: +91 8983743266
E-mail address: anuprita7@gmail.com