AGGRESSIVE VARIANT OF ORAL VERRUCOUS CARCINOMA WITH EXTENSIVE MANDIBULAR INVOLVEMENT ...€¦ ·...

R.S. Sathawane: Aggressive variant of oral verrucous carcinoma with extensive mandibular involvement: a rare case

report

International Journal of Innovations in Dental Sciences / April 2017 / Vol 2 / Issue 1 41

AGGRESSIVE VARIANT OF ORAL VERRUCOUS CARCINOMA

WITH EXTENSIVE MANDIBULAR INVOLVEMENT: A RARE

CASE REPORT

Dr. R.S. Sathawane1, Dr. Nikita Agrawal

2, Dr. Abhijeet Deoghare

3, Dr. Deepti Patel

2

1. Professor and Head

2. Post graduation student

3. Reader

Department of Oral Medicine and Radiology,

Chhattisgarh Dental College and Research Institute, Sundra, Rajnandgaon,

Chhattisgarh, India

PIN- 491441

Address for correspondence-

Dr. Nikita Agrawal, A/66, Amrapali society, Dhamtari road, Raipur, (C.G.) PIN- 492001

Phone no. +91 7748806666

Email- [email protected]

ABSTRACT

Spit tobacco associated malignancy includes two varients: Oral verrucous carcinoma

(OVC) and oral squamous cell carcinoma (OSCC). OVC was first reported by Ackermann in

1948.1 It is a rare, distinct low grade variety of well differentiated OSCC.

2 OVC is painless, slow

growing, looking like cauliflower with thick white warty surface, locally invasive and rarely

metastasize.1 Rarely, the adjacent tissues including bone & cartilage may be involved and

destroyed. Here we report a case of aggressive variant of OVC with extensive mandibular

destruction.

Key Words

Spit tobacco, Aggressive, Oral Verrucous carcinoma, Oral squamous cell carcinoma, Extensive

bone destruction


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INTRODUCTION

Oral verrucous carcinoma (OVC), a

rare, distinct low grade variety of well

differentiated OSCC, was first reported by

Ackermann in 1948. Various terminologies

used in literature for this entity include

Ackerman’s tumor, Buschke-Loewenstein

tumor, florid oral papillomatosis,

epithelioma cuniculatum, and carcinoma

cuniculatum.1 OVC is a rare, distinct low

grade variety of well differentiated OSCC.2

It is painless, slow growing, looking like

cauliflower with thick white warty surface,

locally invasive and rarely metastasize.1 The

most common sites of oral mucosal

involvement are the buccal mucosa,

followed by the mandibular alveolar crest,

gingiva, and tongue.3 In 1980, Shear and

Pindborg4 described a condition called as

verrucous hyperplasia3, and reported that

clinically and pathologically, there is much

resemblance between the two. Verrucous

hyperplasia is said to be an early form of VC

and known to have the same biological

potential.3

Surgery being the first choice of treatment,

and radiotherapy being controversial;

surgery combined with radiotherapy is the

most preferable treatment. Verrucous

carcinoma, a less common tumour,

represents 4.5-9% of oral squamous-cell

carcinomas Males (68.42%) outnumbered

females (31.58%) (2:1). Buccal mucosa

(57.89%) was found to be most commonly

involved followed by tongue, gingiva,

alveolar mucosa, soft palate in decreasing

order. Recurrence rate is high in cases in

which either irradiation or surgery alone is

performed.3

CASE REPORT

A 45years old male reported with a

complain of growth inside mouth since last

3 months. Patient also gave history of

swelling in his lower left side of face since

last 2months which gradually increased to

present size from the first noticed coin sized

swelling. History revealed that the growth

which was present at mandibular left

posterior region, was initially gram nut sized

and then gradually reached to the present

size (3×2cm) in 3months. There was history

of paresthesia of tongue on the affected side,

and no history of discharge from the growth.

There was no relevant medical and

dental history. Patient had the habit of


report


chewing tobacco & gutkha since last

25years and occasional consumption of

alcohol. He used to place gutkha and

tobacco in lower left buccal vestibule for 30

mins, 3-4times/day.

Extraorally a swelling of size approx

4×3cm was evident on left lower 1/3rd of

face involving the left submandibular

region, which was firm and nontender (fig.

1). Left submandibular lymphnodes were

palpable, which were mobile, nontender and

firm in consistency.

Intraorally, a soft tissue overgrowth

of size approx 3 × 2cm was evident distal to

38, in the retromolar area, having

proliferative, cauliflower like surface with

mixed red and white areas (fig. 2). The

growth was slightly tender, non- indurated,

soft to firm on palpation. Unilateral

paresthesia of tongue with no functional loss

was noted on left side.

On the basis of clinical examination,

the provisional diagnosis of verrucous

carcinoma and papilloma was considered in

the differential diagnosis. On investigating,

OPG showed large irregular shaped

radiolucency with ill defined margins and

moth eaten appearance extending from the

mesial root of 38 till above the middle

portion of anterior ramus, covering an area

of approx 4× 1.5cm on left side. The

radiolucency even extended beyond the

periapical area of 38 encroaching the

superior and the superio-anterior border of

the inferior alveolar canal (fig. 3). After

complete haemogram, incisional biopsy of

the lesion was performed, which revealed

hyperkeratotic stratified squamous

epithelium thrown into papillary projections

with underlying supporting connective tissue

cores showing abundant vascularity. At

places the epithelium showed drop shaped

rete ridges growing towards connective

tissue. The suprabasilar epithelial cells were

hyperchromatic at some places and some

epithelial cells were koilocytic. The

underlying connective tissue stroma was

fibrocellular with numerous endothelium

lined blood vessels filled with RBCs.

Moderate inflammatory cells infilterate

chiefly comprising of lymphocytes were

seen, all suggestive of verrucous carcinoma

(fig. 4).

Looking at the aggressive nature of

the OVC, again an incisional biopsy from


report


the other site of the lesion was taken and the

diagnosis was reconfirmed as OVC. So, the

final diagnosis of aggressive oral verrucous

carcinoma with extensive bone involvement

was made. The patient was referred to the

higher centre for the combination

(radiotherapy and surgery) therapy11

.

DISCUSSION

VC has been described in three main

sites: the oropharynx, genitalia and feet.5

Million & Cassiss regarded it as a 'grade

one-half' SCC.6 In the oral cavity, VC

constitutes 2 to 4.5 % of all forms of SCC,

seen mainly in males above 50 years of age,

associated with tobacco use.2

In oral cavity,

it occurs most commonly in the buccal

mucosa (61.4%) > lower alveolus (11.9%).6

This is also associated with high incidence

(37.7%) of second primary tumor

synchronus or metachronus, mainly in oral

mucosa.2 Its etiopathogenesis is described as

biologic (HPV), chemical (smoking) and

physical (constant trauma).7 Its prognosis is

excellent because of its slow growth and

gravity with which it metastasize to regional

lymph nodes. Rarely, the adjacent tisssues

including bone and cartilage may be invaded

and destroyed. Microscopically, VC are

usually broad based and locally invasive

with papillary fronds consisting of highly

differentiated squamous cell lacking usual

criteria of overt malignancy. Rarely mitosis

is seen. Surface is usually covered by keratin

layers. The invasive margin is invariably a

slow ‘pushing’ one along with inflammatory

reaction in the stroma.2

Alkan et al3 reported only 12 cases in 10

years duration. Furthermore, Idris et al, in

their epidemiological study, found no such

tumor reflecting its rarity.1 Rajendran et al.

8,

in their study of 426 cases of OVC, found

the incidence of bone invasion to be 1.2%.

Oliveira et al.9 did not find bone invasion in

their series.10 Instead extensive bony

invasion by the tumor has been seen in our

case. Verrucous hyperplasia, verrucous

keratosis, and verrucous carcinoma may not

be distinguished clinically or may coexist. It

should be kept in mind that verrucous

hyperplasia may also develop from

leukoplakic lesions, and it may transform

into verrucous carcinoma or squamous-cell

carcinoma, acting as a potential

precancerous lesion12.


report


FIGURES

Fig. 1: showing swelling and facial asymmetry of

left side of the face

Fig. 2: showing cauliflower like growth in left

retromolar area

Fig. 3: showing extensive bony destruction

involving apical region of 38, anterior ramus

inferior alveolar canal.

Fig. 4: showing hyperkeratotic and

epithelium with inflammatory infilterate.


report


REFERENCES

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April.2015; 51(1):1-5

2. Singh K, Kalsotra P et al. Verrucous

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December 2004; 6(4),:220-222

3. Alkan A, Bulut E et al. Oral

Verrucous carcinoma. European

Journal of Dentistry. April 2010;

4:202-207

4. Shear M, Pindborg JJ. Verrucous

hyperplasia of the oral mucosa.

Cancer. 1980; 46:1855-1862.

5. Suen K, Wijeratne S and Patrikios J.

An unusual case of bilateral

verrucous carcinoma of the foot.

JSCR 2012; 12:1-3

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.An bras Dermatol, Rio de Janeiro.

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VijayakumarT. Ackerman’s tumour

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9. Oliveira DT, Moraes RV,

FiamenguiFilho JF, FantonNeto

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10. Asha ML, Vini K et al. Verrucous

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International Journal of Advanced

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11. Prabhu MN, et al. Early diagnosis of

periodontal disease based on host

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Healing in Periodontics”,

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796.

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