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Citation:Libyan Dent J 2014, 4:17317742 - http://dx.doi.org/10.5524/LDJ.v4i0. 17317742
(Page numberis not for citation purpose).
1
ORAL VERRUCOUS CARCINOMA: A REPORT OF THREE
CASES
Smit Singla1, Raghavendra Kini2, Vathsala Naik2, Anjali Shetty2
1) Department Of Oral Medicine & Radiology, Teerthanker Mahaveer Dental College, Moradabad, India
2) Department of Oral Medicine & Radiology, A.J. Institute of Dental Sciences, Mangalore, India
ARTICLE INFORMATION:
Article History:
Received: 6 January, 2014
Accepted in revised form: 1February
2014
Published: 8 July 2014
Corresponding author:
Smit Singla
E-mail: smitcool2@yahoo.co.in
Keyword:
Verrucous carcinoma, buccal
mucosa, alveolar mucosa
14012
14012
84012
smitcool2@yahoo.co.in
ABSTRACT:
Verrucous carcinoma (VC) orAckerman’s tumor is a low grade variant of oral
squamous cell carcinoma (OSCC). Although it occurs in other anatomic sites, most
intraoral cases involve buccal mucosa, alveolar mucosa and gingiva. The typical
features of VC that differ from the usual oral epidermoid carcinoma is it generally
slow growing, chiefly exophytic and superficially invasive at until late in the
course of the disease and have low metastatic potential. This paper presents three
variable cases of oral VC along with their clinical and histopathological features.
VC
VC
VC
Smit Singla et al
Citation:Libyan Dent J 2014, 4:17317742 - http://dx.doi.org/10.5524/LDJ.v4i0. 17317742
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INTRODUCTION:
errucous carcinoma is a variant of
squamous cell carcinoma that can
affect cutaneous and mucosal surfaces.
Different terms are used to describe
this tumor, including Ackerman’s tumor,
Buschke Loe wenstein tumor, florid oral
papillomatosis, epithelial cuniculatum and
carcinoma cuniculatum1, 2. The ages range from
50 to 80 years with a male predominance and the
median age is 67 years3, 4. VC may grow very
large and can destroy adjacent tissue such as
bone and cartilage5.Clinical feature depends on
several factors such as duration of lesion, degree
of keratinization along with changes in adjacent
mucosa. The developed carcinoma shows an
exophytic gray to red bulky lesion with a rough,
shaggy, papillomatous surface. The term
‘verrucous’ is used because of its fine, finger
like surface projections6, 7. It may grow into soft
tissue and invade bone, regional lymph nodes
are usually tender but metastasis is rare. It is
usually associated with chronic exposure to UV-
rays, prolonged use of tobacco and its products
including betel nut and snuff. It is also called
“snuff dipper’s cancer”. The oncogenic viruses
HPV 16 and 18 are also implicated in the
etiology8.
CASE SERIES:
Case-1
A 58 years old male patient reported to the
department with a chief complaint of pain on left
cheek since 4 months. Patient noticed it 4 months
back, pain was intermittent, moderate in
intensity and does not vary with postural
variation. Pain was associated with ulcer since
two months. No history of discharge and
paresthesia. Patient used to chew mixture of
areca nut, tobacco and lime 8-10 times from last
30 years. On intraoral examination an exophytic
ulcer proliferative growth was present on left
buccal mucosa measuring about 6X2 cm
extending from commissural area to retro molar
area at the line of occlusion. Overlying mucosal
surface was rough, irregular covered with
slough. Erythematous pinpoints was inter
dispersed throughout the lesion with rolled out
edges,Fig1. Basic findings on palpation,
differential diagnosis and procedure (biopsy and
surgical excision) done were the same for cases
1 and 2 (as discussed below).
Fig: 1. An exophytic ulcer proliferative growth on left buccal
mucosa extending from commissural area to retro molar area at the
line of occlusion.
Surgical excision was done with including
normal surrounding mucosa and reconstruction
with collagen membrane graft was done, Fig2.
Fig:2. post-operative after reconstruction with collagen membrane
graft
Case-2
A female patient aged 60 years, reported with a
chief complaint of pain on right cheek since 6
months. Patient noticed it 6 months back, pain
was intermittent, moderate in intensity and does
not vary with postural variation. Pain was
associated with ulcer since six months. No
history of discharge and paresthesia. Patient
used to chew mixture of areca nut, tobacco and
lime 6-8 times from last 20 years. On intraoral
examination an exophytic ulcer proliferative
growth was present on right buccal mucosa
measuring about 6X5 cm extending superior-
inferiorly from lower right buccal vestibule to
upper right buccal vestibule and extending to the
right maxillary edentulous ridge and anterio-
posteriorly from right commissural area
involving the lower lip to retromolar area.
Overlying mucosal surface was rough, irregular
covered with slough. Erythematous pinpoints
was inter dispersed throughout the lesion with
rolled out edges, Fig3.
V
Smit Singla et al
Citation:Libyan Dent J 2014, 4:17317742 - http://dx.doi.org/10.5524/LDJ.v4i0. 17317742
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Fig: 3. exophyticulcero proliferative growth on right buccal
mucosa
On palpation all relevant inspectory finding
were confirmed. Ulcero-proliferative growth
was tender on palpation, firm in consistency and
ulcer was indurated at the margins. Surface was
irregular with well-defined edges. Right
submandibular lymph nodes were palpable two
in number, mobile, firm in consistency and non-
tender. Based on the history and clinical findings
provisional diagnosis of verrucous carcinoma of
left buccal mucosa was made. Squamous cell
carcinoma and metastatic carcinoma were
considered under differential diagnosis. Incisional
biopsy was done and revealed loss of parakeratin
is projecting into rete ridges and suggestive of
verrucous carcinoma Fig4.
Fig: 4. histological conformation of verrucous carcinoma
Surgical excision was done with including
normal surrounding mucosa and reconstruction
with collagen membrane graft was done, Fig5.
Fig: 5. post-operative after reconstruction with collagen membrane
graft
Case-3
A 65 year old female patient reported to the
department with a chief complaint of pain on the
left cheek since last 4 months. Patient noticed it
4 months back. Pain was intermittent, moderate
in intensity and does not vary with postural
variation. Pain was localized and according to
patient pain was due to crack on lip and not
aware of growth on the buccal mucosa. Pain
increased while eating and decreased after
eating. Past medical and dental histories were
noncontributory. Patient used to chew areca nut,
tobacco, slaked lime 5 to 6 times daily from last
20 years. Patient used to chew and used to keep
in the oral cavity for around 15-20 minutes.
After keeping 15-20 minute patient used to spit
the stuff. An exophytic ulcero-proliferative
growth was present on left buccal mucosa
measuring about 3x2 cm. extending from
commissural area at the line of occlusion, Fig6.
Fig:6.exophyticulcero-proliferative growth on left buccal mucosa
extending from commissural area at the line of occlusion
Overlying surface is rough covered with slough
having erythematous pinpoints with rolled out
edges. On palpation lesion was firm in
consistency with indurations at the margins and
does not bleed on palpation. Surface was
irregular with well- defined edges. Based on
clinical examination carcinoma of left buccal
mucosa was given. Verrucous carcinoma was
considered under differential diagnosis.
Incisional biopsy was done and revealed
parakeratin plugging, rete ridges are bulbous,
epithelial margin appears to be pushing into the
connective tissue with intact basement
membrane and suggestive of Verrucous
carcinoma. Surgical excision of the lesion with
surrounding tissue was done. Follow up of one
year was done for all the three cases till that
there was no recurrence.
Smit Singla et al
Citation:Libyan Dent J 2014, 4:17317742 - http://dx.doi.org/10.5524/LDJ.v4i0. 17317742
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DISCUSSION:
Due to its benign indolent behavior, most of the
time it will go unrecognized or unchallenged by
the patient. Earlier lesion starts as verrucous
hyperplasia, later it become vegetant and
clinically resembles verrucous leukoplakia.
Evolution of verrucous carcinoma from primary
lesion takes months to years9. It occurs in elderly
patient around 60 to 70 years of age similar to
our case series. It is more common in men as
compared to women whereas we found 2 cases
in women out of 3 cases 3, 4.Verrucous carcinoma
constitutes 2 to 4.5% of all forms of squamous
cell carcinoma in the oral cavity 6.Verrucous is
usually associated with the use of tobacco and
its products as seen in our all the three cases.
Clinical features vary depends upon the duration
and keratinization of the lesion. Typically lesion
is a pale, warty, fungating, locally aggressive,
ulcerated tumor attached by a broad base, is well
circumscribed and it is clearly demarcated from
the adjacent mucosa. Tumor has a predominant
horizontal growth, it tend to erode more than
infilterate10. Regional lymph node metastases are
exceedingly rare. Ferlito et al. (1980)
emphasized on the following classic description
for the diagnosis of verrucous carcinoma: a)
Fungating warty tumor, b)Thickened club
shaped, papillomatous projections which push
rather than infiltrate into the underlying tissue,
c) Deeply projecting cleft like spaces with
degenerating keratin and later cystic
degeneration of central portion of the filiform
projections, d)High degree of cellular Differ-
entiation with absence of features of
malignancy, e)Considerable inflammatory
response in invaded tissues, f)Rare regional
lymph node and distant metastasis11. There are
four clinic pathologic types: (1) an urogenital:
giant condyloma acuminatum, Buschke- Loe-
wenstein tumor, giant malignant condyloma,
verrucous carcinoma of the anogenital mucosa,
carcinoma-like condyloma, and condylomatoid
Precancerosis, (2) oro-aerodigestive: Ackerman
tumor, verrucous carcinoma of Ackerman, oral
florid papillomatosis, (3) Feet: epithelioma
cuniculatum, carcinoma cuniculatum, (4) Other
cutaneous sites: cutaneous verrucous carcinoma,
papillomatosis cutis carcinoides, papillomatosis
cutis12. Buccal mucosa is most commonly
affected site followed by mandibular retromolar
and molar area (41.6%) followed by the buccal
mucosa. (16.6%), the hard palate (16.6%), the
floor of the mouth (16.6%), and the lip mucosa
(8.3%) 2. Microscopically, verrucous carcinomas
consist of thickened club shaped filiform
projections lined with thick, well-differentiated
squamous epithelium with marked surface
keratinisation (“church-spire” keratosis).
Parakeratin typically fills the numerous clefts or
crypts (parakeratin plugs) between the surface
projections as was seen in our case reports.
Clinically verrucous hyperplasia and verrucous
carcinoma are indistinguishable. In 10 to 20%
cases following irradiation biological behavior
of small proportion of verrucous carcinoma are
reported within extremely short latent period,
called anaplastic transformation. Some authors
don’t believe in this ‘dedifferentiation’
phenomenon and account this observation due to
presence of ‘hybrid tumors’, i.e. presence of foci
of less differentiated squamous cell carcinoma
within verrucous carcinoma6. Management of
oral verrucous carcinoma include adequate oral
hygiene and surgical excision of the lesion with
adequate margins is the treatment of the choice
and prognosis is good as done in our all the
cases. Surgical excision can be done with laser
which provides the bloodless field. If cervical
lymph nodes were palpable then ultra sound
guided fine needle aspiration biopsy were
advised, in our cases there was no cervical
lymphadenopathy. Depending upon the lymph
node metastasis supraomohyoid or redundant
neck dissection can be done15. Irradiation alone
or in combination with surgery is rarely
performed. Combined therapy can be useful
when the tumor extends to the retromolar area.
When surgery is not indicated, other treatment
modalities such as cytostatic drugs may be
preferred. Various dosages of cytostatic drugs
have been proven to show beneficial effects in
reducing tumor size; α-interferon (IFN) seems to
support the therapy by delaying the growth of
the tumor but does not take the place of surgery
alone2. “No matter what the treatment is, the rate
of local recurrences is said to be high ranging
from 30% to 50% and not unusually is the result
of inadequate surgery because of the size of the
tumor and left dysplasia close to the verrucous
carcinoma”13.
CONCLUSION:
Verrucous carcinoma is frequently misdiagnosed.
So, it is the need of the hour for the cooperation
Smit Singla et al
Citation:Libyan Dent J 2014, 4:17317742 - http://dx.doi.org/10.5524/LDJ.v4i0. 17317742
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between clinician and pathologist to prevent the
misdiagnosis. So that verrucous carcinoma
should be diagnosed at the early stage to prevent
the effect on the quality of life of the
patients14.Different modes of treatment
modalities are present based on the different
presentations of the lesion.
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