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Original Article
Verrucous carcinoma: A study of
10 cases
Amit Agnihotri, Deepshikha Agnihotri1
Departments of Oral and Maxillofacial Surgery and 1Prosthodontics, Guru Gobind Singh College of Dental Science and
Research Centre, Burhanpur
ABSTRACT
Background: Verrucous carcinoma is a unique clinico pathological variant of squamous cell
carcinoma, occurring mainly in oral cavity and larynx, buccal mucosa being most commonly
involved. The aim of this clinical study was to identify clinical and histopathological features
of the verrucous carcinoma of oral cavity.
Materials and Method: 10 patients who had developed oral verrucous carcinoma. In this
study, the diagnostic criteria included clinical and histopathological features of the lesions.
Results: All the patients were diagnosed with verrucous carcinoma following incisional
biopsy. Buccal mucosa was the most affected site (50%), followed by the palate (10%), the
alveolar ridge and gingiva (10%) and the lip mucosa (10%). Cigarette smoking (40%) was
the main etiological factor of the verrucous carcinoma.
Conclusion: The overall study concluded that verrucous carcinoma is more prevalent in
males than in females and most of the patients were chronic cigarette smokers. So there
emerge a necessity to differentiate between the different variants of Squamous cell carcinoma.
Key words: Verrucous carcinoma, verrucous hyperplasia, ackerman’s tumor
Introduction
Address Correspondence:
Dr. Amit Agnihotri,
Department of Oral and Maxillofacial
Surgery, Guru Gobind Singh College of
Dental Science and Research Centre,
Lalbagh Road,
Burhanpur, India.
E‑mail: dramit_agnihotri@yahoo.com
Date of Submission: 02‑04‑2012
Date of Acceptance: 12‑07‑2012
Access this article online
Website:
www.indjos.com
DOI:
10.4103/0976-6944.106459
Quick Response Code:
Verrucous carcinoma (VC) is a highly
differentiated variant of squamous cell
carcinoma (SCC) and is a very rare entity,
first described by Ackerman in 1948.[1]
Various synonyms used to describe this
tumor, including Ackerman’s tumor,
Buschke Loewenstein tumor, florid oral
papillomatosis, epithelioma cuniculatum,
and carcinoma cuniculatum. [2] It is a
special form of squamous cell carcinoma
with specific clinical and histological
features. The tumor is slow growing, locally
destructive, invasive in nature and rarely
metastasizes. It appears as a painless, white,
warty, exophytic plaque attached by a broad
base resembling a cauliflower. It is seen more
commonly in men than in women in 6th or
7th decade of life. The most common sites
of oral mucosal involvement include the
buccal mucosa, followed by the mandibular
alveolar crest, gingiva, and tongue. Schrader
et al.[3] and Jordan[4] suggested verrucous
carcinoma as a slow‑growing exophytic
Indian Journal of Oral Sciences  Vol. 3  Issue 2  May-Aug 2012
lesion that spreads by lateral extension and
is locally destructive, but if neglected, can
invade the periosteum and the bone. The
exact etiology of verrucous carcinoma is
unknown, tobacco chewing and smoking is
found to be the causative factors. Poor oral
hygiene, oral lichenoid reaction, and oral
leukoplakia may act as predisposing factors.
Shear and Pindborg[5] described a condition
termed verrucous hyperplasia. Verrucous
hyperplasia and verrucous carcinoma,
both lesions closely resemble each other
clinically and histopathologically. Verrucous
hyperplasia has been considered as an
early form of verrucous carcinoma and
is believed to have the same biological
potential.[6,7] Various treatment modalities
include surgery, chemotherapy, radiation or
combination of these and photodynamic
therapy, [8] which has been recently
reported. Surgery has been the first
choice of treatment for these lesions, and
radiotherapy is controversial;[9] however,
surgery combined with radiotherapy is the
next most preferable treatment and may
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Agnihotri and Agnihotri: Verrucous carcinoma: A study of 10 cases
have benefits, particularly in cases of extensive lesions.
Recurrence rate is high in cases, in which either irradiation
or surgery alone is performed.
The purpose of this study is to discuss our experience with
10 cases of oral verrucous carcinoma with an analysis of
the literature and to identify the clinical relationship between
verrucous carcinoma and its similar pathological entities.
Materials and Method
10 cases reported to the department of oral and maxillofacial
surgery. The diagnosis was confirmed by clinical and
histopathological features of the lesions. All patients were
treated with surgery as their initial management. The
follow‑up time ranged from 9 to 13 months.
Results
The clinical details are summarized in Table 1. Among the
10 patients (age range: 32‑67, mean age: 49.9 years, 8 males
and 2 females in a ratio of 4:1 in sequence), lesions affected
a variety of intraoral sites. The buccal mucosa was the
most affected site (50%), followed by the palate (10%), the
gingival and alveolar crest (10%), the retromolar trigone
(10%) and the lip mucosa (10%), respectively. Patients’
medical history revealed no systemic diseases. Clinically,
all the lesions were cauliflower‑shaped exophytic lesions
[Figure 1]. One patient also had an exophytic growth
extending to the palate associated with the lesion [Figure 2],
and 1 patient had a leukoplakic area extending to the lip
mucosa associated with the lesion [Figure 3]. Four patients
had exophytic growth on buccal mucosa [Figure 4]. Out
of 10 patients, 4 patients were smokers of cigarettes alone.
Among these patients, 1 had smoked cigarettes for 14 years
(more than one pack a day), and 3 had been smoking for
30 years (more than two packs a day). In the study, 1 patient
was using alcohol and cigarettes together for 25 years, and
1 was using tobacco and cigarette together for 15 years,
whereas 1 patient was using tobacco alone for 12 years.
2 patients had no possible etiologic factors.
No regional lymph node involvement was found in an
extraoral examination of all cases. An incisional biopsy was
taken from all lesions, and the specimens were examined
histopathologically. Verrucous carcinoma was diagnosed
following histopathological examination of the incisional
biopsy specimens. General histopathological characteristics
of the specimens revealed acanthosis, papillomatosis, and
hyperkeratosis of the epithelium of the lesion, continuing
with characteristics of healthy mucosa [Figures 5-7].
Squamous epithelial cell composition of the tumors did
not give a definite atypical character, but showed blunt
rete processes toward the subepithelial area. Lymphocyte
infiltration was noted in the periphery of the tumor islands.
All of the patients were treated with surgery alone. Elective
neck dissections were performed in all 10 patients (100%)
as part of their initial surgical treatment. All of the
neck specimens were negative for metastasis after detail
pathology examination. For the repair of surgical defects,
2 patients (20%) had free flap reconstructive surgeries,
which were performed by a plastic surgeon, and others
had reconstruction with buccal fat pad.
Table 1: Clinical summary of the patients
Age
Sex
Location
Possible etiological factor
Treatment done
Tobacco chewing
Elective neck dissection and
reconstruction done with free flap
Elective neck dissection and
reconstruction done with buccal fat pad
Elective neck dissection and
reconstruction done with buccal fat pad
Elective neck dissection and
reconstruction done with buccal fat pad
Elective neck dissection and
reconstruction done with buccal fat pad
Elective neck dissection and
reconstruction done with buccal fat pad
Elective neck dissection and
reconstruction done with buccal fat pad
Elective neck dissection and
reconstruction done with buccal fat pad
Elective neck dissection and
reconstruction done with free flap
Elective neck dissection and
reconstruction done with buccal fat pad
34
M
32
M
Buccal mucosa, Gingiva
and alveolar ridge
Gingiva and alveolar ridge
48
M
Buccal mucosa
Unknown etiology
61
F
Hard palate
Cigarette smoking
55
M
Lip mucosa
Cigarette smoking
43
M
Retromolar trigone
67
F
Buccal mucosa
Tobacco chewing and Cigarette
smoking
Cigarette smoking and alcohol
49
M
Buccal mucosa
Leukoplakia
47
M
Mandible, PAC
Cigarette smoking
63
M
Buccal mucosa
Unknown etiology
Cigarette smoking
Follow‑up
period
10 months
12 months
12 months
13 months
11 months
12 months
12 months
13 months
12 months
9 months
Avg. 49.9 Abbreviations: M: Male, F: Female, PAC: Posterior alveoler crest
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Agnihotri and Agnihotri: Verrucous carcinoma: A study of 10 cases
Figure 1: Cauliflower‑shaped exophytic lesions
Figure 2: Exophytic growth extending to the palate associated with
the lesion
Figure 3: Leukoplakic area extending to the lip mucosa associated
with the lesion
Figure 4: Exophytic growth on buccal mucosa
Figure 5: Microscopic aspects supporting diagnosis of verrucous
carcinoma. Note the broad pushing blunt squamous epithelial
downgrowths that are diagnostic of verrucous carcinoma
(Haematoxylin and Eosin, x 4)
The 1‑year overall survival rate and tumor control rate was
100%. At the time of follow‑up, no patient had suffered
from recurrence in the primary site or neck area.
Indian Journal of Oral Sciences  Vol. 3  Issue 2  May-Aug 2012
Figure 6: Papillomatosis and hyperkeratosis of well differentiated
squamous epithelium with keratin plunging (x 10 magnification –
Hematoxylin and Eosin staining)
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Agnihotri and Agnihotri: Verrucous carcinoma: A study of 10 cases
always large, exophytic, soft, fungating, slow growing
neoplasms with a pebbly mamillated surface.[9] The lesion
appears as a diffuse, well‑demarcated, painless, thick
plaque with papillary or verruciform surface projections
resembling a cauliflower.[11]
Figure 7: Histological details of an area with mild basal cytological
atypia: vesicular nuclei with prominent eosinophilic nucleoli
(Haematoxylin and Eosin, x 40)
Discussion
Verrucous carcinoma most of the times goes unrecognized
due to benign behavior of tumor.[10] Verrucous Carcinoma
(Snuff Dipper’s Cancer; Ackerman’s Tumor) is a variant
of oral squamous cell carcinoma characterized by a
predominantly exophytic overgrowth of well‑differentiated
keratinizing epithelium having minimal atypia and with
locally destructive pushing margins at its interface with
underlying connective tissue.[1,6,7] Verrucous carcinoma
(VC), first described in 1948 by Lauren V. Ackerman, is
a distinct variant of differentiated SCC with low grade
malignancy, slow growth and no or only low metastatic
potential.[9] The tumor may also be found on different
sites including skin, paranasal sinus, bladder and anorectal
region, male and female genitalia, sole of the foot, and
ear.[9] It is often associated with long‑term use of smokeless
tobacco although examples occur among non‑users.[11]
Schrader et al,[3] and Jordan[4] have reported that verrucous
carcinomas were slow‑growing, exophytic, well‑demarcated
hyperkeratotic lesions. These typically present as extensive,
white, and warty lesions. All the lesions in this case series
were similar in clinical behavior and aspect.
The etiology of verrucous carcinoma is not well‑defined.
Human papilloma virus (HPV) has been considered one of
the causative factors.[11] Smoking seems highly associated
with the development of mucosal verrucous carcinoma
of the neck and head. Poor oral hygiene, presence of oral
lichenoid, and leukoplakic lesions may act as predisposing
factors. In Asia, leukoplakia is known to be associated with
smoking, smokeless tobacco, and chewing habits and a
synergistic effect has also been found.[13]
Shear and Pindborg[5] reported that out of 28 patients with
verrucous lesions, 24 (86%) used tobacco, and one was an
areca quid chewer. Tobacco appears to be a major factor
in causation of verrucous lesions. In our patients, cigarette
smoking seemed the most causative factor among those
mentioned above.
Verrucous hyperplasia and verrucous carcinoma are
indistinguishable clinically.[6] verrucous hyperplasia probably
represents a morphological variant of verrucous carcinoma
by Slootwage and Muller[13] (1983). An essential feature
in distinguishing verrucose hyperplasia from verrucose
carcinoma is the location of the thickened epithelium
with respect to adjacent normal appearing epithelium. In
hyperplasia, most of the hyperplastic broadened rete ridges
lay above the adjacent normal epithelium while verrucous
carcinoma on contrary exhibits a downward growth pattern
of otherwise similar rete ridges.[14]
Verrucous carcinoma is found predominantly in men
older than 55 years of age. In areas where women are
frequent users of spit tobacco, however, elderly females
may predominate. In our study, the men predominated,
and the mean age was 49.9 years. In our study, we found
the male and female ratio was 4:1, which was similar to the
study done by Hansen et al.[12]
Shear and Pindborg [5] noted that 36 of 68 patients
had verrucous hyperplasia associated with leukoplakic
lesions. Similarly, our study revealed 1 patient having
verrucous hyperplasia accompanied by leukoplakic lesions.
Differential diagnosis can be made histologically, but a
biopsy specimen should be sufficient for correct diagnosis.
Verrucous hyperplasia generally does not extend into
deeper tissues but is superficial to normal epithelium,
whereas verrucous carcinoma extends more deeply.[5,6] In
our cases, the clinical diagnosis was verrucous hyperplasia,
whereas final diagnosis was verrucous carcinoma following
the incisional biopsy. In our patients, histopathologic
appearance was concurrent with those mentioned in the
literature.
The most common sites of oral mucosal involvement
include the mandibular vestibule, the buccal mucosa,
and the hard palate.[1,5,7,9] Oral verrucous carcinoma has a
characteristic gross appearance. These lesions are almost
In the current literature,[15] the most common site for
verrucous carcinoma was the buccal mucosa; in our
study, we also found the most common site was buccal
mucosa (50%) followed by the palate (10%), alveolar ridge
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Agnihotri and Agnihotri: Verrucous carcinoma: A study of 10 cases
(10%), gingiva (10%), and lip mucosa (10%). In verrucous
carcinoma, regional lymph nodes are often tender and
enlarged because of inflammatory involvement, simulating
metastatic tumor;[16] contrarily, lymph nodes were not
affected in our patients. Verrucous carcinoma typically has
a heavily keratinized, or parakeratinized, irregular clefted
surface with parakeratin extending deeply into the clefts.[16]
Our cases presented histopathological findings similar to
those mentioned above.
The prognosis of verrucous carcinoma is better than that of
other kinds of life‑threatening malignant tumors. Various
treatment modalities include surgery, chemotherapy,
radiation, or combination of these and photodynamic
therapy,[8] which have been recently reported. The use of
buccal fat pad has increased in popularity because of its
reliability, ease of harvest, and low complication rate. It
has been used as a pedicle or free graft in reconstructing
small to medium‑sized defects intraorally.
Surgery is considered the primary mode of treatment for
verrucous carcinoma. Irradiation alone or in combination
with surgery is rarely performed. Combined therapy can
be useful when the tumor extends to the retromolar area.
Koch et al,[17] suggested that patients with oral cavity VC
treated with surgery first had better survival. In this study,
we treated all of the patients with surgery first and then
reconstruction.
McClure et al,[18] reported that extensive lesions in the oral
cavity may benefit from combined therapy. When surgery is
not indicated, other treatment modalities such as cytostatic
drugs may be preferred; α‑interferon (IFN) seems to
support the therapy by delaying the growth of the tumor
but does not take the place of surgery alone.
Ferlito and Recher[19] reported that neck dissection is
not indicated in laryngeal verrucous carcinoma because
laryngeal VC has so far never metastasized to the cervical
lymph nodes or to other organs.
Verrucous hyperplasia and verrucous carcinoma may
not be distinguished clinically. It should be kept in mind
that verrucous hyperplasia may transform into verrucous
carcinoma or squamous‑cell carcinoma, acting as a
potential precancerous lesion. All our cases were verrucous
Indian Journal of Oral Sciences  Vol. 3  Issue 2  May-Aug 2012
carcinoma. Thus, both clinicians and pathologists must be
careful about warty and exophytic lesions in the oral cavity.
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How to cite this article: Agnihotri A, Agnihotri D. Verrucous carcinoma:
A study of 10 cases. Indian J Oral Sci 2012;3:79-83.
Source of Support: Nil, Conflict of Interest: None declared
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