Snuff Dipper's Cancer

What Is Snuff Dipper's Cancer or Verrucous Carcinoma?

It was originally known as Ackerman's tumor (defined by Ackerman in 1948); this slow-growing low-grade, and well-differentiated variant of squamous cell carcinoma involves the lip, oropharyngeal, and pharyngeal mucosal linings. This verrucous pattern of cancer presents itself as leukoplakic patches orally in the mucosal linings that gradually invade the underlying jaw bone when they progress in size and extent.

What Are the Clinical Features of Snuff Dipper's Cancer?

1. The clinical presentation of this lesion is usually diffuse, painless, and may often cause severe pain and masticatory difficulty to the patient on chewing food.

2. The most common site of this squamous cell carcinoma is the,

• Gingiva.

• Buccal mucosa.

• Alveolar mucosa.

• Hard palate.

• The floor of the mouth.

3. The fact to be noted about this lesion is that only when it grows to a clinically appreciable size, the patient can notice its presence as it is not only uncommon but also a neoplasm that is very slow-growing with an exophytic keratotic surface.

4. Because of the strong linkage and association as per research with the continued or chronic use of tobacco or betel nut chewing, it became known as snuff dipper's cancer.

5. The general incidence of this cancer is seen more with a male predisposition and in the seventh to eighth decades of life. It is not rare or uncommon to find some chronic users of tobacco and betel nut suffer from this cancer in their middle ages and above, usually 60 years of age.

6. Chronic alcoholism or alcohol consumption and certain gene mutations of head and neck cancers have been reported in western countries as risk factors or potential causes for developing this cancer variant.

What Are the Forms of Smokeless Tobacco and TSNAs?

Smokeless tobacco, also known by various other names like snuff, dip, spit, chew, or spitless tobacco, is an unsafe alternative to cigarette smoking. Not only does this form of tobacco have an equally addictive impact upon the user like any other nicotine product, but it exhibits a quick form of absorption of nicotine directly through the oral epithelium compared to cigarette smoking. This leads to an increased nicotine level in the bloodstream directly.

TSNAs or tobacco-specific nitrosamines are carcinogenic agents of nicotine that are very frequently known to be the risk factors for inducing precancerous lesions like leukoplakia and slow healing white lesions of the oral cavity apart from lung cancer, esophageal cancer, pharyngeal cancer, throat cancer, stomach cancer, and pancreatic cancer.

According to the definition by the national cancer institute, TSNAs are formed when the tobacco leaves are grown, cured, aged, and processed eventually. The forms of smokeless tobacco are available as loose leaves, plugs, or flavored or unflavored twists of dried tobacco. These individuals are habituated or often addicted to the placement of smokeless tobacco between the cheek mucosa and the gingival tissue or in between the chewing surfaces of the teeth anteriorly or posteriorly. Women in western countries, especially in the rural areas, have been reported to place snuff in the gingivobuccal grooves, and they present clinically with verrucous cancer at this site.

Moist snuff is usually used on the teeth between the lower lips and the gum (the lower anterior teeth affected), and dry snuff comes in a powdered form that may be inhaled or sniffed through the nostrils. Many nicotine abusers and users are not aware of the dangers of daily betel nut chewing and instead consider this to be a safe alternative option to daily cigarette smoking in an attempt to quit smoking. But research shows smokeless tobacco users are 2.5 times more prone to cancer development in comparison to smokers, and smokers are 5-6 times more prone to develop cancer than nonsmokers.

What Histopathological Features Help Diagnose Snuff Dipper's Cancer?

For establishing the diagnosis as verrucous carcinoma, the dental or maxillofacial surgeon will primarily perform a routine biopsy (brush or incisional biopsy) for histopathologic examination and rule out lesions of differential clinical diagnosis. On microscopic examination, pathologists report the presence of dense keratinization, dyskeratosis, lymphoplasmacytic infiltration at the lesion base, and cytologic atypia.

The squamous down growth of the epithelium is usually confirmative of verrucous cancer. Pathologists may require re-biopsy in certain cases for ascertaining the diagnosis, and maxillofacial surgeons or dentists should study the patient's medical and clinical history before confirming the lesion as a verrucous variant.

What Is the Differential Diagnosis of Snuff Dipper's Cancer?

• Salivary gland carcinomas like adenoid cystic carcinoma, mucoepidermoid carcinoma, and polymorphous low-grade carcinoma.

• Lymphomas.

• Benign oropharyngeal tumors.

• Squamous cell carcinoma of the lip.

• Basal cell carcinoma.

How Is Snuff Dipper's Cancer Managed?

In the majority of the verrucous carcinoma cases, nodal metastasis is absent, and cervical adenopathies can be present. Neck dissection is not recommended for verrucous carcinoma, and hence the surgeon or oncologist prefers surgical resection of the lesion to be the main treatment modality for eliminating this cancer.

The role and effect of radiation therapy are controversially used only by certain practitioners to improve patient prognosis. However, radiotherapy is not contraindicated and is used for therapeutic healing and follow-up for a few months by some physicians. Also, depending on the successful elimination of the tumor (as this remains an aggressive but low-grade cancer), chemotherapy may not be recommended in most cases following surgery.

Chemotherapy and radiotherapy course is recommended only based upon the clinical extent of the lesion and its consecutive elimination. Proper oral hygiene, regular dental check-ups, and six-monthly oral prophylaxis, along with a complete cessation of smokeless tobacco, will aid in a good prognosis. Apart from the people who have cancer of this variant, individuals addicted to smokeless tobacco or snuff or nicotine addictions or cigarette smoking can be advised prescription antidepressant medications by the physician such as Varenicline and Bupropion SR for cessation of nicotine addiction. Self-medication, however, is strictly contraindicated without the prescription or advice by the physician or oncologist, or maxillofacial surgeon.

Conclusion:

To conclude, nicotine addiction and addiction to smokeless tobacco forms remain major factors for snuff dipper's cancer in the older population. Cessation of smoking and nicotine from a younger age will prevent risk factors. Also, proper time management by the dental surgeon in the diagnosis of verrucous cancer will ensure a good prognosis for the patient.