Manuscript Name

Oral Verrucous Carcinoma: A Case Report

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)

Corresponding Author:

Dr. Santosh Patil,
Dept of oral medicine and radiology, Jodhpur Dental College, Jodhpur National University,
Jhanwar road, Naranadi,
Jodhpur (Raj).342001, India.
Fax: +912931281416
E-mail: drpsantosh@yahoo.com

Abstract:

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 old male patient is being reported who presented with verrucous carcinoma and homogenous leukoplakia.

Introduction:

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 in the genitalia, 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 Because of the finger like structures projecting from the surface of the lesion, the term verrucous has been used.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

Case Report:

A sixty-year-old male reported to us with a complaint of slowly proliferative lesion on the left check and lower lip since two years. The patient gave a history of tobacco smoking and chewing since forty years. There was no significant family history and 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. Surface of the lesion was rough and shaggy (Figure 1, 2 3 and 4). Along with this a grayish white non-scrapable patch was seen on right buccal mucosa which extended till commisure of the mouth (Figure 5). No regional lymph nodes were palpable. A clinical diagnosis of verrucous carcinoma involving lower lip and left buccal mucosa, along with homogenous leukoplakia of the right buccal mucosa was made. 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

Figure 1: Extraoral photograph of the patient.

Figure 2: Clinical photograph showing finger like projections.


Figure 3: Involvement of the lower lip.	Figure 4: Lesion extending into the left buccal mucosa.	Figure 5: White lesion on the right buccal mucosa.

Discussion:

The etiology and pathogenesis of verrucous carcinoma is not well established. Human papilloma virus (HPV) has been considered one of the possible etiologic factors.⁸ 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 placed habitually.⁹ But 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 ridge, retromolar area, gingiva, rare cases involving the tongue have reported in literature.^12,13 The tumor clinically presents as a thickened plaque or a bulky mass with a rough shaggy warty or papillary surface.^7,9 These features depend on various factors like duration, degree of keratinization, host inflammatory response and the changes in adjacent mucosa. Verrucous carcinoma needs to be differentiated from verrucous hyperplasia, well-differentiated squamous cell carcinoma, papillary squamous cell carcinoma and squamous papilloma.

Verrucous hyperplasia and verrucous carcinoma are indistinguishable clinically. Histopathological examination can only help in differentiating these lesions.¹⁰ Controversies exist in literature in regards to considering VC as a distinct clinico-pathological entity or as a part of histologic continuum of leucoplakia.^14,15 VC presents with characteristic histopathological features. It comprises a heavily keratinized, or parakeratinized, irregular clefted surface with parakeratin typically filling the numerous clefts. Retiridges are wide and elongated. No significant cellular atypia is seen routinely and usually a chronic subepithelial inflammatory infiltrate is noted.¹⁶ Histological Appearance of the Patient's Tumor is shown on the right.

Verrucous carcinoma has excellent prognosis because of its slow growth and gravity with which it metastasize to regional lymph nodes.¹⁷ Complete surgical resection of the tumor is considered as the best management for VC. The extent of surgical margin and the adjuvant radiotherapy are still controversial. Wide field surgical resection with good onco-clearance 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 only help in reducing in the size of the lesion temparaily.¹⁰

Conclusion:

Since verrucous carcinoma was first identified as a distinct clinicopathologic entity, confusion exists 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. Histopathologists and the practitioners together can efficiently achieve the task of prompt diagnosis and timely management of verrucous carcinoma.

References:

1. Bouquot JE. Oral verrucous carcinoma. Incidence in two US populations. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998 Sep;86(3):318-24. View Abstract

2. Ackerman L. Verrucous carcinoma of the oral cavity. Surgery 1948;23:670-8.

3. Medina JE, Dichtel W, Luna MA. Verrucous-squamous carcinoma of the oral cavity: a clinicopathologic study of104 cases. Arch Otolaryngol 1984;110:437-40.

4. Tornes K, Bang G, Koppang HS, Pedweson KN. Oral verrucous carcinoma. Int J Oral Surg 1985;14:485-92.

5. Mehta FS, Hammer JE. Tobacco related, oral mucosal lesion and conditions in India. Publication: Basic dental research unit. Tata Institute of fundamental reaserch. 1983; 3: 4.

6. Demian SD, Bushkin FL, Echevarria RA. Perineural invasion and anaplastic transformation of verrucous carcinoma. Cancer 1973;32:395-401.

7. Singh K, Kalsotra P, Khajuria R and Manhas M: Verrucous carcinoma (Ackerman’s Tumor) of mobile tongue. JK Science 2004;6(4):220-222.

8. Eversole LR. Papillary lesions of the oral cavity: relationship to human papillomaviruse. J Calif Assoc 2000;28:922-927.

9. Neville BW, Day TA. Oral cancer and precancerous lesions. CA Cancer J Clin 2002;52:195-215.

10. Alkan A, Bulut E, Gunhan O, Ozden B. Oral verrucous carcinoma: a study of 12 cases.Eur J Dent. 2010 Apr;4(2):202-7.

11. Regezi AJ, Sciuba JJ, Jordan RCK. Oral pathology clinical pathological correlations. 5th edition. St. Louis Missouri: Saunders Elsvier; 2008.

12. Kawakami M, Yoshimura K, Hayashi I, Ito K, Hyo S. Verrucous Carcinoma of the Tongue: Report of two cases. Osaka Med Coll 2002;50(1-2):19-22.

13. Carrozzo M, Carbone M1, Gandolfo S, Valente G, Colombatto P, Ghisetti V. An atypical verrucous carcinoma of the tongue arising in a patient with oral lichen planus associated with hepatitis C virus infection. Oral Oncol 1997;33(3):220-25.

14. Bataakis JG, Hybels R, Crissman JD, Rice DH. The pathology of head and neck tumors : verrucous carcinoma. Part 15. Head Neck Surg 1982;5:29.

15. Sheer M. Pindborg J.J verrucous hyperplasia of the oral mucosa. Cancer 1980; 46: 1855.

16. Shafer WG, Hine MK, Levy BM. A Textbook of Oral pathology. Philadelphia, WB: Saunders Company; 1983. Benign and malign tumors of the oral cavity; pp. 127-130.

17. Mehta FS, Hammer JE. Tobacco related, oral mucosal lesion and conditions in India. Publication: Basic dental research unit. Tata Institute of fundamental reaserch. 1983; 3: 4.