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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 70-73

Atypical variation of oral verrucous carcinoma: A comprehensive case report


1 Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bengaluru, Karnataka, India
2 Department of Ear, Nose, and Throat, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
3 Department of Oral Pathology and Microbiology, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bengaluru, Karnataka, India

Date of Web Publication8-Sep-2016

Correspondence Address:
Santosh Nagesh Holenarasipur
Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.189975

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   Abstract 

Verrucous carcinoma is a clinical variant of squamous cell carcinoma. It is a locally aggressive lesion having a characteristic grayish-white warty appearance. This case report presents one such case having atypical features of verrucous carcinoma. Although nodal involvement is rare, it was seen in the present case, thus warranting wide local excision with supraomohyoid neck dissection.

Keywords: Metastasis, squamous cell carcinoma, verrucous carcinoma


How to cite this article:
Holenarasipur SN, Nagaraj T, Batlahalli MV, Tathanahalli YL. Atypical variation of oral verrucous carcinoma: A comprehensive case report. J Indian Acad Oral Med Radiol 2016;28:70-3

How to cite this URL:
Holenarasipur SN, Nagaraj T, Batlahalli MV, Tathanahalli YL. Atypical variation of oral verrucous carcinoma: A comprehensive case report. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2022 Jul 3];28:70-3. Available from: https://www.jiaomr.in/text.asp?2016/28/1/70/189975


   Introduction Top


Verrucous carcinoma is a common clinical variant of squamous cell carcinoma which appears as slowly enlarging warty, exophytic overgrowth which appears gray or white, present commonly on the buccal mucosa or gingiva and is commonly seen in older men.[1] The clinical behavior of verrucous carcinoma shows a locally invasive pattern rarely with any distant metastases and fair prognosis. Clinical and histopathologic diagnosis of verrucous carcinoma is difficult due to the indolent growth of this tumor and its benign histologic features.[2] Tobacco consumption has been the primary etiology of verrucous carcinoma. However, human papillomavirus (HPV) strains have also been indicated as a cause for verrucous carcinoma. The treatment for verrucous carcinoma is usually surgical excision. Since the rate of nodal metastasis is less, neck dissection and radiotherapy are the least opted modalities of treatment.


   Case Report Top


A 59-year-old male patient visited the Department of Oral Medicine with a chief complaint of a growth on the lower right back teeth region since 2 months. The patient gave a history of a slow-growing growth in the region which was asymptomatic except for occasional bleeding during brushing. The patient did not give any history of tobacco consumption. Patient's medical history was noncontributory. However, the patient had visited the dentist few months back for root canal treatment. Extra-oral examination revealed a solitary palpable right submandibular lymph node, measuring about 2 cm, tender, soft to firm in consistency and mobile. On clinical examination, a sessile warty, mixed red and white growth was present on the attached gingiva extending from the lower right canine to the lower right second molar tooth both buccally and lingually. The surface appeared corrugated on the buccal aspect with well-defined margins [Figure 1]. On palpation, it was rough, nontender, and soft in consistency. The lesion on the lingual aspect showed a contrasting picture. The growth was sessile with a rough surface which appeared erythematous [Figure 2]. On palpation, the growth was nontender, soft in consistency with bleeding on digital manipulation. Grade III mobility was present in relation to 45, 46. Based on the clinical examination, a provisional diagnosis of verrucous hyperplasia was made. The patient was advised routine hematologic examination along with routine serologic investigations for human immunodeficiency virus and hepatitis B antigen. However, the report was noncontributory. Hence, the patient was advised incisional biopsy. Histopathology report revealed parakeratinized stratified epithelium with mild dysplastic features such as intraepithelial keratinization. Few pleomorphic and prominent nucleoli were present. Most of the epithelium showed parakeratin plugging with few areas of necrosis within the epithelium [Figure 3] and [Figure 4]. Focal koilocytes were present in the epithelium [Figure 5]. The underlying connective tissue showed chronic inflammatory infiltrate and endothelium lined capillaries. The histopathology report suggested verrucous carcinoma. The patient was thereafter subjected to neck ultrasound which revealed 18 × 8 mm right submandibular node with necrotic component and subcentimetric level I node. Based on the clinico histopathologic findings and the ultrasound report, a wide local excision of the lesion with right selective neck dissection was done. The reconstruction was done with the right pectoralis major myocutaneous flap under general anesthesia [Figure 6].
Figure 1: Mixed red and white warty growth on the buccal aspect

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Figure 2: Warty erythematous growth on the lingual aspect

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Figure 3: Epithelium showing exophytic and endophytic growth with parakeratin plugging, acanthosis of spinous layer (10×)

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Figure 4: Broad-pushing borders of rete pegs, with no loss of continuity in the basement membrane with mild dysplasia in the epithelium (10×)

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Figure 5: Intraepithelial koilocytes (10×)

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Figure 6: Postoperative picture showing reconstruction with pectoralis major myocutaneous flap

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   Discussion Top


The prevalence of oral verrucous carcinoma for total carcinomas affecting the oral cavity and oropharynx is low, and according to Rekha andAngadi it is between 2 and 12% respectively.[3] Verrucous carcinoma is a warty variant of squamous cell carcinoma which is characterized by a predominantly exophytic overgrowth of well-differentiated keratinizing epithelium. The rate of malignant transformation of verrucous carcinoma to squamous cell carcinoma is almost 100%.[4] Histopathologically, verrucous carcinoma is characterized by parakeratin plugging, pushing borders of the rete pegs with no loss of continuity of basement membrane. Occasional presence of koilocytes is indicative of HPV as a cause of verrucous carcinoma.[5] Varying terminologies used for describing verrucous carcinoma adds to the complexity in the diagnosis. In 1948, Ackerman reported 31 cases of verrucous carcinoma and thus coined the term verrucous carcinoma. Besides it has also been named as verrucous hyperplasia, proliferative verrucous leukoplakia, carcinoma cuniculatum and oral florid papillomatosis.[6] The common variants of verrucous carcinoma are pure verrucous carcinoma and hybrid verrucous carcinoma. Hybrid oral verrucous carcinoma has foci of squamous cell carcinoma.[7] The general presentation of verrucous carcinoma is whitish keratotic growth. However, the presentation of this case was unusual as it was a mixed red and white lesion. The presence of red component along with white is suggestive of an active inflammatory reaction which could be a fallout of chronic inflammatory reaction due to chronic periodontitis.

The second unusual presentation in this case was the presence of metastatic nodes. Verrucous carcinoma is locally aggressive, but metastases are seldom.[8] Although the treatment approach for verrucous carcinoma remains liberal surgical excision. Cervical dissection is controversial in verrucous carcinoma.[9] However, this approach is justified in cases of nodal metastasis in hybrid verrucous carcinoma. The recurrence in 2-year follow-up has been 7.69% and in 5-year follow-up has been a skewed 0–66.7%. The survival rate in verrucous carcinoma is excellent at 93.65%.[10]


   Conclusion Top


Verrucous carcinoma of the oral cavity has varied clinical presentation. The rate of malignant transformation to squamous cell carcinoma remains high. Although it is a locally aggressive lesion with rare nodal metastases, the decision to do a conservative neck dissection is reserved for the hybrid type of verrucous carcinoma.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Spiro RH. Verrucous carcinoma, then and now. Am J Surg 1998;176:393-7.  Back to cited text no. 1
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2.
Thomas GJ, Barrett AW. Papillary and verrucous lesions of the oral mucosa. Diagn Histopathol 2009;15:279-85.  Back to cited text no. 2
    
3.
Rekha KP, Angadi PV. Verrucous carcinoma of the oral cavity: A clinico-pathologic appraisal of 133 cases in Indians. Oral Maxillofac Surg 2010;14:211-8.  Back to cited text no. 3
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4.
Walvekar RR, Chaukar DA, Deshpande MS, Pai PS, Chaturvedi P, Kakade A, et al. Verrucous carcinoma of the oral cavity: A clinical and pathological study of 101 cases. Oral Oncol 2009;45:47-51.  Back to cited text no. 4
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5.
Eisenberg E, Rosenberg B, Krutchkoff DJ. Verrucous carcinoma: A possible viral pathogenesis. Oral Surg Oral Med Oral Pathol 1985;59:52-7.  Back to cited text no. 5
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6.
Kallarakkal TG, Ramanathan A, Zain RB. Verrucous papillary lesions: Dilemmas in diagnosis and terminology. Int J Dent 2013;2013:298249.  Back to cited text no. 6
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7.
Kolokythas A, Rogers TM, Miloro M. Hybrid verrucous squamous carcinoma of the oral cavity: Treatment considerations based on a critical review of the literature. J Oral Maxillofac Surg 2010;68:2320-4.  Back to cited text no. 7
[PUBMED]    
8.
Asproudis I, Gorezis S, Aspiotis M, Tsanou E, Kitsiou E, Merminga E, et al. Orbital metastasis from verrucous carcinoma of the oral cavity: Case report and review of the literature.In Vivo 2007;21:909-12.  Back to cited text no. 8
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9.
Ogawa A, Fukuta Y, Nakajima T, Kanno SM, Obara A, Nakamura K, et al. Treatment results of oral verrucous carcinoma and its biological behavior. Oral Oncol 2004;40:793-7.  Back to cited text no. 9
[PUBMED]    
10.
Candau-Alvarez A, Dean-Ferrer A, Alamillos-Granados FJ, Heredero-Jung S, García-García B, Ruiz-Masera JJ, et al. Verrucous carcinoma of the oral mucosa: An epidemiological and follow-up study of patients treated with surgery in 5 last years. Med Oral Patol Oral Cir Bucal 2014;19:e506-11.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


This article has been cited by
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[Pubmed] | [DOI]



 

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