Verrucous Carcinoma

Verrucous Carcinoma

Verrucuous carcinoma is an uncommon kind of well-differentiated squamous cell carcinoma. The most common site of origin of this type of cancer normally develops in gingiva (gums), alveolar mucosa and buccal mucosa of the oral cavity or buccal cavity. It rarely occurs in the floor of the mouth and tongue. Larynx, esophagus, ear canal, bladder, rectum, soles of feet, vagina or penis are the other sites where it may also develop. It may also co-exist with classical squamous cell carcinoma. Ackerman first reported the disease in 1948 and therefore the disease is called Ackerman’s carcinoma or tumor.

Types 

1. Type I or Oral florid papillomatosis

2. Type II or Anogential type verrucous carcinoma

3. Type III or Epithelioma cuniculatum

4. Type IV

Epidemiology

Verrucuous cancer is more frequent in males over 60 years of age. The reported rate of Verrucous carcinoma among all types of squamous cell carcinoma is 2-9%. Verrucous carcinoma is among the least common of the oral carcinomas, representing only 3% of the total. The disease is more common in males.

Causes or risk factors

  • Tobacco Chewing
  • Snuff dipping habits – Moistened smokeless tobacco – it is also called “snuff-dipper’s cancer”
  • Immunosuppression
  • Human papillomavirus and other viruses
  • Alcohol consumption

Clinical presentation

  • Slow growing, exophytic, papillary growth having a white pebbly surface.
  • Surface shows multiple rugae-like folds with deep clefts in between. They are hyperkeratinized.
  • Can be one or many in number
  • The clinical behavior of verrucuous carcinoma can be destructive despite its deceptively benign microscopic appearance.
  • Regional lymph nodes are tender and enlarged due to secondary infection.
  • Verrucuous carcinomas may grow very large and extensively infiltrate and destroy adjacent structures, including bone and cartilage.
  • Although it is able to show extensive local invasion, verrucuous cancer metastasize very rarely from the site of origin. Lymph node and distant metastasis are rare during all stages of this tumor.
  • There have been observations that they tend to recur in the form of less-differentiated carcinomas.

Symptoms

Pain, tenderness and dysphagia (indications of verrucous carcinoma in buccal mucosa)

Lesions in the gingiva and alveolar mucosa become rapidly fixed to the bone and cause its destruction.

Diagnosis:

Accurate diagnosis of verrucous carcinoma remains an important problem. Verrucuous carcinoma cells appear benign and therefore resembles some other benign lesions like leukoplakia, papilloma, pseudoepitheliomatous hyperplasia, verrucous hyperplasia, as well as from grade I squamous carcinoma. Deeply infiltrating portions of the lesion should be excised during biopsy.

Verrucous carcinoma can be diagnosed based on certain histological features. Molecular approaches can also help in diagnosing verrucuous carcinoma as opposed to squamous cell carcinoma.

CT scan can be done to study the infiltrations of verrucous carcinoma to bones and cartilages and their destruction.

Treatment:

Treatment to some extent depends on the site of verrucuous cancer.

Surgical Excision: Surgical resection remains the choice treatment for verrucuous cancer. Complete resection of verrucous carcinoma can completely cure the disease.

Laser Therapy: Carbon dioxide laser surgery is a better option of treatment than radiotherapy. The carbon dioxide laser may be employed for some surgical procedures in treating verrucuous carcinoma. For example, Type I or II carbon dioxide laser cordectomy is a safe, feasible, secure method of treating verrucous carcinoma of the vocal folds. Most recurrent disease was manageable locally with repeated surgery.

Radiotherapy: Radiotherapy could be used only in selected clinical settings, when surgery is not possible. For example, radiotherapy can be effectively used for verrucous carcinoma of the larynx that cannot be resected with preservation of laryngeal function. It can also be used in combination with surgery.

However, a high rate of recurrence or persistence of tumor has been observed after radiotherapy has shown. Reports on the role of radiotherapy in the management of verrucuous carcinoma are controversial since they are said to be radioresistant. In many cases, “anaplastic transformation” has been observed following radiotherapy. However, there are some reports that show radiotherapy and surgery are equally effective in treating this form of cancer.

Prognosis:

Prognosis is good for this type of carcinoma. The 5-year survival rate is very high in most types of verrucuous carcinoma. The disease is curable if diagnosed properly.

References:

  1. Paul J. Donald (2010) The Difficult Case in Head and Neck Cancer Surgery. Publisher: Thieme Medical Pub.
  2. Koch H, Kowatsch E, Hödl S, Smola MG, Radl R, Hofmann T, Scharnagl E. (2004) Verrucous carcinoma of the skin: long-term follow-up results following surgical therapy. Dermatol Surg. (8):1124-30.
  3. A. Santoro,G. Pannone,M. Contaldo, F. Sanguedolce, V. Esposito, R. Serpico, L. Lo Muzio, S. Papagerakis, and P. Bufo A (2011) Troubling Diagnosis of Verrucous Squamous Cell Carcinoma (“the Bad Kind” of Keratosis) and the Need of Clinical and Pathological Correlations: A Review of the Literature with a Case Report Journal of Skin Cancer Volume 2011, Article ID 370605, 4 pages
  4. Hod R, Feinmesser R, Shvero J. (2010) Carbon dioxide laser cordectomy for verrucous carcinoma of vocal folds. J Laryngol Otol. ;124(1):55-8.
  5. This article was originally published on September 3, 2012 and last revision and update was 9/4/2015.