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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
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 42
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
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 43
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
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 44
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.
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 45
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.
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 46
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