Journal of Advanced Clinical and Research Insights

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Verrucous carcinoma of left mandibular alveolar mucosa - A case report
  JCRI
CASE REPORT
Verrucous carcinoma of left mandibular alveolar mucosa -
A case report
Tejavathi Nagaraj, H. N. Santosh, Swati Saxena, C. K. Sumana
Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences, Bengaluru, Karnataka, India
Correspondence: Dr. Swati Saxena, Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences, Bengaluru - 560 032, Karnataka, India.
Phone: +91-9015660832.
E-mail: swatisaxen@gmail.com
Received 20 December 2017;
Accepted 22 January 2017
doi: 10.15713/ins.jcri.197
 
ABSTRACT
Verrucous carcinoma is a low-grade variant of squamous cell carcinoma (SCC). It is mainly reported in head and neck region, but it has a predilection of oral cavity and larynx. Clinically, it appears as a proliferative growth along with finger-like projections or a cauliflower-like appearance which plays a significant role in its diagnosis. Most commonly, it is seen in tobacco user males. It is difficult to diagnose verrucous carcinoma histopathologically. Verrucous carcinoma is often described as a benign lesion. It has minimum aggressive potential, but transformation into SCC has been seen in long-standing cases. Thereby, early diagnosis of the lesion is very necessary, and its surgical excision is the most appropriate treatment modality of verrucous carcinoma. In this paper, we discuss a case of 78-year-old female with verrucous carcinoma of left lower alveolar mucosa.
Keywords:Oral squamous cell carcinoma, verrucous carcinoma,verrucous hyperplasia
How to cite this article: Nagaraj T, Santosh HN, Saxena S,Sumana CK. Verrucous carcinoma of left mandibular alveolarmucosa - A case report. J Adv Clin Res Insights 2018;5:12-14.
 
 

Introduction

Lauren V Ackermann in 1948 described oral verrucous carcinoma (OVC) as a low-grade variant of squamous cell carcinoma (SCC) and so it was known as "Ackermann's tumor" or "verrucous carcinoma of Ackermann."[1] In literature, various names have been used for verrucous carcinoma such as florid oral papillomatosis, Buschke-Lowenstein tumor, carcinoma cuniculatum, and epithelioma cuniculatum.[2] The most common site of occurrence includes oral cavity and various other sites being pyriform sinus, larynx, paranasal sinuses and nasal cavity, esophagus, lacrimal duct, external auditory meatus, skin, penis, scrotum, vagina, vulva, uterine cervix, perineum, and leg.[3,4]

Among the oral mucosa, the most common sites include the buccal mucosa, followed by the mandibular alveolar crest, gingiva, and tongue. There is a predilection for male in the sixth decade with a slow-growing rate in OVC. It may invade locally if treatment is not appropriate. Distant metastasis is rare in verrucous carcinoma.[5] Clinically, it appears as a thick, painless, white plaque, giving it resemblance with a cauliflower.[6] Most commonly associated etiologies with OVC are smoking and smokeless form of tobacco, opportunist viral infections, and alcohol. This article reports a case of a female patient with OVC with differential diagnosis.

 
Case Report

A 78-year-old female patient reported to the Department of Oral Medicine and Radiology, Sri Rajiv Gandhi College of Dental Sciences and Hospital, Bengaluru, with a chief complaint of pain in left lower back tooth region for 2 weeks. A history of presenting illness revealed that pain started 2 weeks back, which was severe, continuous, aggravated on wearing denture, and got relieved by analgesics. Medical history revealed that the patient was hypertensive, diabetic, anemic, and was having hypothyroidism and was under medication for the same. The patient had a habit of betel nut chewing which she had quit for 30 years.

The patient gave no relevant family history. She was a denture wearer for 10-12 years.

Normal gait and posture were seen on general examination. Furthermore, the patient was well oriented, conscious, and moderately built. Evidence of pallor was present. In extraoral examination, there was no abnormality detected. Regional lymph nodes were non-palpable.

On intraoral examination, completely edentulous maxillary and mandibular arches were revealed and a well-defined exophytic growth on the lingual aspect of left lower posterior alveolar ridge extending up to the retromolar area with white component extending up to the pterygomandibular raphe [Figure 1]. The growth was extending lingual to the left ventralaspect of the tongue, showing cauliflower-like growth. Thesurface of the growth appeared erythematous and papillary. Onpalpation, the growth was firm inconsistency and tender. Lesionwas raised from adjacent mucosa with firm and irregular margins.Furthermore, the tongue appeared depapillated from the tip ofthe tongue to posterior one-third area. The oral hygiene of thepatient was fair.

12 Journal of Advanced Clinical & Research Insights, January-February, Vol 5, 2018

Verrucous carcinoma - A case report Nagaraj, et al.

Verrucous carcinoma of the left mandibular alveolar mucosawas given as provisional diagnosis. Differential diagnosis ofSCC and verrucous hyperplasia was given. Hematologicalinvestigations along with thyroid, lipid profile, and blood sugarestimation were done which was under normal limits anddiabetes was under control.

Radiographically, completely edentulous maxillary andmandibular arches are seen without any invasion into the bone[Figure 2].

The lesion was excised under local anesthesia, and postsurgicalinstructions were given [Figure 3]. The specimenof excised lesion was sent for histopathological examination[Figure 4]. Uneventful satisfactory healing occurred after1 month.
Follow-up of the patient has been done.

Verrucous carcinoma of left mandibular alveolar mucosa - A case report
Figure 1: Intraoral picture showing exophytic growth on the leftmandibular alveolar mucosa

Verrucous carcinoma of left mandibular alveolar mucosa - A case report
Figure 2: Orthopantomogram showing completely edentulousmaxillary and mandibular arches

 
Microscopic features

The section (H and E stained) revealed stratified squamousepithelium with para keratinization. The epithelium washyperplastic in nature with its down growth into the cellularconnective tissue. The epithelium was having dysplasticfeatures such as basal cell hyperplasia, cellular and nuclearpleomorphism, individual cell keratinization, and keratinpearl formation within broad and elongated rete ridges. Focalarea of keratin plugging was also seen. The connective tissueunderlying the epithelium was scanty and had infiltration ofinflammatory cells with few endothelial lined blood vessels[Figure 5].

Diagnosis of the case

On the basis of clinical as well as histopathological findings,diagnosis of verrucous carcinoma was given.

Verrucous carcinoma of left mandibular alveolar mucosa - A case report
Figure 3: Showing surgical excision of the lesion

Verrucous carcinoma of left mandibular alveolar mucosa - A case report
Figure 4: Excised specimen

Journal of Advanced Clinical & Research Insights, January-February, Vol 5, 201813

Nagaraj, et al. Verrucous carcinoma - A case report

Verrucous carcinoma of left mandibular alveolar mucosa - A case report
Figure 5: Histopathological picture showing parakeratin plugging,keratin pearls and areas of inflammation

Discussion

OVC, as described before, occurs most commonly in eldermale with tobacco chewing or smoking habit and alcoholconsumption.[5] However, the case we reported here is ofelder female with a thick exophytic growth having cauliflowerlikeappearance seen in her left mandibular alveolar mucosa,which had been proven histologically as verrucous carcinoma.Although Ackerman's tumor or OVC has a predilection fororal cavity, esophagus involvement has also been reported insome cases. In Ackerman's study, 11 patients of 18 (i.e., 61%)with OVC were tobacco chewers.[7] Some studies have alsoshown an association of verrucous carcinoma and humanpapillomavirus. Low socioeconomic status, ill-fitting dentures,poor oral hygiene, snuff, tobacco smoking and chewing, andalcohol use are some of the causative factors. Some factorsthat can predispose the individuals to the development ofpremalignant lesions are oral submucous fibrosis, leukoplakiaand erythroplakia. Leukoplakia was found in association withOVC in 48% of patients in a study done by Rajendran et al.[8]It has been reported that long-standing leukoplakia withouttreatment can change into OVC. The buccal mucosa is the mostcommon site in oral cavity followed by mandibular alveolarmucosa. OVCs mostly present as a large, soft, fungating,exophytic growth, and having pebbly surface along with locallyaggressive nature. Often lymphadenopathy is seen but is oftenreactive. The differential diagnosis of verrucous carcinomaincludes (i) proliferative verrucous leukoplakia, (ii) SCC, and(iii) Verrucous hyperplasia.

 
The best treatment modality for OVC as per the literatureis the surgical resection of tumor. Therefore, this patient wasadvised for surgical removal of the lesion, followed by regularcheckup. Distant metastasis is generally not seen in case of OVCs.Recurrence of lesion can be seen because of improper section.

Conclusion

Verrucous carcinoma, in most of the cases, is clinicallyindistinguishable from verrucous hyperplasia and verrucouskeratosis, hence in order to give appropriate diagnosishistopathological evidence is necessary. It is more common inmales and is generally asymptomatic and painless. In this case,we report a case of a female with painful exophytic, warty lesionof left mandibular alveolar mucosa which was histopathologicallyproved to be verrucous carcinoma. OVC which is associatedwith leukoplakia, erythroplakia, and submucous fibrosis maybe an indication of "field cancerization" and can have multiplerecurrences, so regular follow-ups are highly suggestive in suchpatients.

References
  1. Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery1948;23:670-8.
  2. Schwartz RA. Verrucous carcinoma of the skin and mucosa.J Am Acad Dermatol 1995;32:1-21.
  3. Spiro RH. Verrucous carcinoma, then and now. Am J Surg1998;176:393-7.
  4. Ferlito A, Recher G. Ackerman's tumor (verrucous carcinoma)of the larynx: A clinicopathologic study of 77 cases. Cancer1980;46:1617-30.
  5. Oliveira DT, Moraes RV, Filho JF, Neto JF, Landman G,Kowalski LP. Oral verrucous carcinoma: A retrospectivestudy inSao Paulo Region, Brazil. Clin Oral Invest 2006;10:205-9.
  6. Alkan A, Bulut E, Gunhan O, Ozden B. Oral verrucouscarcinoma: A study of 12 cases. Eur J Dent 2010;4:202-7.
  7. Walvekar RR, Chaukar DA, Deshpande MS, Pai PS,Chaturvedi P, Kakade A, et al. Verrucous carcinoma of theoral cavity: A clinical and pathological study of 101 cases. OralOncol 2009;45:47-51.
  8. Rajendran R, Sugathan CK, Augustine J, Vasudevan DM,Vijayakumar T. Ackerman's tumour (verrucous carcinoma) oftheoral cavity: A histopathologic study of 426 cases. SingaporeDent J 1989;14:48-53.

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