Authors: Santosh Patil*, Sumita Kaswan**, Nikita Kalla***, Bharati Doni*
* Reader, ** Professor, *** Intern
Institution: Patil, Kaswan, and Kalla: Jodhpur Dental College, Jodhpur National University, Jhanwar road, Naranadi, Jodhpur (Raj), India; and Doni: Maitri College of Dentistry And Research Sciences Durg (Chhattisgarh)
Dr. Santosh Patil,
Dept of oral medicine and radiology, Jodhpur Dental College, Jodhpur National University,
Jhanwar road, Naranadi,
Jodhpur (Raj).342001, India.
Verrucous carcinoma is an uncommon but distinct variety of well differentiated squamous cell carcinoma. The tumor is chiefly exophytic and does not metastasize, but it can invade and destroy oral tissues. A case of an old male patient is being reported who presented with verrucous carcinoma and homogenous leukoplakia.
Verrucous carcinoma (VC) is a rare slow-growing oral tumor comprising approximately three percent of all primary invasive carcinomas of the oral mucosa.1 Ackerman first described this tumor in 1948, which is also known as Verrucous Carcinoma of Ackermann or Ackermann’s tumor.2 VC may occur in several locations in the head and neck, cutaneous surfaces and on the genitalia. The oral cavity is noted as the most common site of this tumor.3 This tumor is predominantly seen in older men, the age range reported in literature is from 50 to 80 years and the median age being 67 years.4 Histopathology reviels finger like structures projecting from the surface of the lesion, giving rise to the term verrucous.5 This tumor may grow through soft tissue of cheeks, penetrate into mandible or maxilla causing extensive local destruction and invade perineural space if left untreated.6 Regional lymph node metastasis is seen in rare cases and distant metastasis has not been reported.7
A sixty-year-old male reported to us with a chief complaint of a slowly proliferative lesion on the left check and lower lip for two years duratoin. The patient gave a history of tobacco smoking and chewing since forty years. There was no significant family history or medical history. On examination, an exophytic growth was seen on the lower lip extending beyond the left retro-commisure area to involve the buccal mucosa. The lesion was non-tender with raised margins. The surface of the lesion was rough and shaggy (Figure 1, 2 3 and 4). In addition, a grayish white non-scrapable patch was seen on right buccal mucosa which extended up to the commisure of the mouth (Figure 5). No regional lymph nodes were palpable. A clinical diagnosis of verrucous carcinoma involving the lower lip and left buccal mucosa, along with homogenous leukoplakia of the right buccal mucosa was made. An incisional biopsy of both the lesions was carried out and the histopathological report confirmed the clinical diagnosis. The patient was referred to oncology centre for further management.
Pictures of a 60 year old male patient with verrucous carcinoma of the lower lip.
Click on Pictures to Enlarge
The etiology and pathogenesis of verrucous carcinoma is not well established. The human papilloma virus (HPV) is considered as one of the possible etiologic factors.8 In addition, long-term tobacco usage seems to be highly associated with the development of oral verrucous carcinoma of the neck and head. Lesions often develop at the site where the tobacco is habitually placed.9 However, cases have also been reported in non-tobacco users. Poor dental hygiene, oral lichenoid and leukoplakic lesions are considered as predisposing factors in the development of oral verrucous carcinoma.10
VC accounts for 5% of all intraoral squamous cell carcinomas.11 Verrucous carcinoma most commonly occurs on the buccal mucosa, labial mucosa, the mandibular or maxillary vestibule and the mandibular or maxillary alveolar ridges, retromolar area and gingiva. Rare cases involving the tongue have also been reported in literature.12,13
The tumor clinically presents as a thickened plaque or as a bulky mass with a rough shaggy warty or papillary surface.7,9 The type of presentation depends on various factors such as duration, degree of keratinization, host inflammatory response and changes in adjacent mucosa. Verrucous carcinoma needs to be differentiated from verrucous hyperplasia, Pseudoepitheliomatous hyperplasia, well-differentiated squamous cell carcinoma, papillary squamous cell carcinoma and squamous papilloma.
Verrucous hyperplasia and verrucous carcinoma are indistinguishable clinically. Histopathological examination only helps in differentiating these lesions.10 Controversies exist in literature regarding whether VC as a distinct clinico-pathological entity or is a part of histologic continuum of leucoplakia.14,15 VC presents with characteristic histopathological features. It has a heavily keratinized, or parakeratinized, irregular clefted surface with parakeratin typically filling the numerous clefts. Retiridges are wide and elongated. Significant cellular atypia is not usually seen and most often a chronic subepithelial inflammatory infiltrate is noted.16 Histological Appearance of the Patient's Tumor is shown on the right.
Verrucous carcinoma has an excellent prognosis because of its slow growth and rarity with which it metastasizes to regional lymph nodes.3 Complete surgical resection of the tumor is considered as the best management for VC. The extent of the surgical margin and the use of adjuvant radiotherapy are still controversial. Wide field surgical resection with good oncological surgical margins has been preferred by some of the oncosurgeons because of the chances of anaplastic transformation of this tumor.7 Chemotherapy with the usage of cytostatic drugs is also preferred in cases where surgery is not indicated, this may paliate the patient by helping to reducing the size of the lesion temparaily.10
Since verrucous carcinoma was first identified as a distinct clinicopathologic entity, confusion has existed in establishing the proper criteria for diagnosis. It should be distinguished from the usual squamous cell carcinoma because of its local invasiveness, non-metastasizing behavior, and special clinical appearance. Together histopathologists and practitioners can efficiently achieve the task of prompt diagnosis and timely management of verrucous carcinoma.
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