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Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 615
Verrucous carcinoma in association with oral submucous fibrosis

1 Department of Oral Medicine and Radiology, Sathyabama Dental College & Hospital, Chennai, India
2 Department of Oral and Maxillofacial Surgery, Priyadharshini Dental College, Chennai, India
3 Department of Oral Medicine and Radiology, Meenakshi Annal Dental College and Hospital, Chennai, India

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Date of Submission12-Oct-2010
Date of Decision13-Jan-2011
Date of Acceptance08-Mar-2011
Date of Web Publication26-Nov-2011


Oral verrucous carcinoma is a form of well differentiated squamous cell carcinoma characterized by exophytic over growth. It is slow growing and locally invasive tumor occurring in 6 th and 7 th decade of life. Smoking and chewing tobacco is found to be the most common etiological factor of verrucous carcinoma although oral leukoplakia may act as a predisposing factor. This is a rare case of oral varrucous Carcinoma seen in association with oral submucous fibrosis in a younger patient with long standing history of chewing tobacco.

Keywords: Oral submucous fibrosis, squamous cell carcinoma, verrucous carcinoma, verrucous hyperplasia

How to cite this article:
Pravda C, Srinivasan H, Koteeswaran D, Manohar L A. Verrucous carcinoma in association with oral submucous fibrosis. Indian J Dent Res 2011;22:615

How to cite this URL:
Pravda C, Srinivasan H, Koteeswaran D, Manohar L A. Verrucous carcinoma in association with oral submucous fibrosis. Indian J Dent Res [serial online] 2011 [cited 2019 Oct 19];22:615. Available from:
Verrucous carcinoma is a highly differentiated variant of squamous cell carcinoma, first described by Ackermen in 1948. The various synonyms used for this tumor include Ackerman's tumor, Buschke Lowenstein tumor, florid oral papillomatosis, epithelioma cuniculatum, and carcinoma cuniculatum. [1]

The tumor clearly differs from squamous cell carcinoma because it is slow growing, locally destructive and rarely metastatic. It is seen more commonly in men than in women in 6 th or 7 th decade of life.

It appears as a white, warty, exophytic growth attached by a broad base. Schrader et al. and Jordan suggested verrucous carcinoma as a slow-growing exophytic lesion that spreads by lateral extension and is locally destructive, but if neglected can invade the periostium and the bone.

Though the exact etiology of verrucous carcinoma is not well defined, chewing of tobacco and smoking are found to be the causative factors. Poor oral hygiene, oral lichenoid reaction, and oral leukoplakia may act as predisposing factors.

   Case Report Top

A 29-year-old male patient reported with a painless, white proliferative growth in the left buccal mucosa for past 1 year. The patient had the habit of chewing tobacco for past 15 years. Two years before, he developed burning sensation and difficulty in opening the mouth and thereby stopped chewing. One year later, he developed a growth in the left buccal mucosa.

Patient's mouth opening was 2.5 cm [Figure 1]. Blanching and palpable fibrotic bands were present in both right and left buccal mucosa. Two white hairy growths were seen, one in the retromolar area and the other in left buccal mucosa in relation to 36 and 37 [Figure 2]. The surface was rough, firm and nontender. A clinical diagnosis of oral verrucous carcinoma with oral submucous fibrosis (OSMF) was made.
Figure 1: Patient's profile showing limited mouth opening

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Figure 2: White papillary growth involving left buccal mucosa and retromolar area

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Excisional biopsy was done [Figure 3] and the histopathologic diagnosis was verrucous carcinoma of the left buccal mucosa. The epithelium showed hyperparakeratinization with papillary projections and parakeratin plugging in the crypts between the papillary projection with broad and bulbous rete ridges and acanthosis. The underlying connective tissue showed moderate inflammatory cell infiltrate and some areas of hemorrhage and dysplasia [Figure 4] and [Figure 5].
Figure 3: Immediate post-surgical removal of the lesion

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Figure 4: Photomicrograph showing parakeratotic stratified squamous epithelium with parakeratotic plugging

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Figure 5: Photomicrograph showing the epithelium

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The patient was treated for OSMF with intralesional steroids and hyaluronidase. The patient's mouth opening has improved and the patient is regularly followed up. There is no evidence of recurrence.

   Discussion Top

The etiology of verrucous carcinoma is not well defined. Persons who use smokeless tobacco are at a higher risk of developing verrucous carcinoma than non-tobacco users. Human papilloma virus has been identified in the cells of this tumor but is still undetermined. It may occur as a consequence of snuff dipping or as a later stage of papillary verrucous leukoplakia.

According to Shear and Pindborg, tobacco chewing appears to be the major causative factor for verrucous carcinoma. [2] Documented cases show the existence of verrucous carcinoma in association with tobacco pouch or leukoplakia, but the association with OSMF is found to be rare.

OSMF is a precancerous condition associated with chronic betel nut chewing. The development of squamous cell carcinoma is seen in one-third of the OSMF patients, but the development of verrucous carcinoma is rare in such patients.

Chang et al., [3] in their study, suggested that chewing areca quid is the major risk factor in the development of verrucous hyperplasia and verrucous carcinoma.

A distinction should be made between verrucous hyperplasia and verrucous carcinoma. Verrucous hyperplasia was described by Shear and Pindborg in 1980. [2] It is more superficial and does not extend deeper than the surrounding normal epithelium. It shows dysplasia and can later develop into verrucous carcinoma or squamous cell carcinoma.

Verrucous carcinoma, on the other hand, extends more deeply, pulling the adjacent normal epithelium at its margin. It is diagnosed by histopathologic examination following excisional biopsy. Bulut et al., [4] in their study on 12 cases of oral verrucous carcinoma, showed that it is difficult to distinguish verrucous hyperplasia and verrucous carcinoma clinically. Verrucous hyperplasia is an antecedent or early form of verrucous carcinoma and should be treated as verrucous carcinoma and a close follow-up should be made.

Most of the verrucous carcinoma that develops in smokeless tobacco users occurs in older individuals who have practiced the habit for several years. The tumor occurring in younger individuals has been rarely documented. Friedell and Rosenthal [5] in 1941 reported eight cases of verrucous carcinoma; all were men over 60 years. Ackerman in 1948 reported 31 cases of verrucous carcinoma in old men with many years of duration of tobacco chewing. Sorger in 1960 [6] reported four cases of verrucous carcinoma in men above 70 years. Ours is the youngest case to be reported with verrucous carcinoma.

The most common sites of occurrence in oral cavity are buccal mucosa and gingiva. Emel Bulut's study showed mandibular posterior alveolar crest and retromolar trigone to be the most commonest sites of involvement, followed by buccal mucosa, palate and floor of the mouth. [4]

Surgery is the primary mode of treatment of verrucous carcinoma. Combined therapy with irradiation is found to be useful when the tumor extends to the retromolar region. Cyctostatic drugs like alpha interferon can be used as a supportive therapy where surgery is contraindicated. It helps in delaying the growth of the tumor. Prognosis of verrucous carcinoma is excellent after complete surgical removal. Local recurrence may occur with incomplete excision of the tumor.

Verrucous carcinoma can develop de nova or from preexisting leukoplakia and in older individuals. OSMF, a premalignant condition caused by chronic betel nut chewing, can also lead to the development of verrucous carcinoma irrespective of the age of the patient.

   References Top

1.Schwartz RA. Verrucous carcinoma of the skin and mucosa. J Am AcadDermatol 1995;32:1-21.  Back to cited text no. 1
2.Shear M, Pindborg JJ. Verrucous hyperplasia of the oral mucosa. Cancer 1980;46:1855-62.  Back to cited text no. 2
3.Chen BL, Lin CC, Chen CH. Oral verrucous carcinoma: an analysis of 73 cases. Clin J Oral MaxillofacSurg 2000;11:11-7.  Back to cited text no. 3
4.Alkan A, Bulut E, Gunhan O, Ozden B. Oral verrucous carcinoma: A study of 12 cases. Eur J Dent 2010;4:202-7.  Back to cited text no. 4
5.Friedell HL, Rosenthal LM. The etiologic role of chewing tobacco in cancer of the mouth: Report of eight cases treated with radiation. J Am Med Assoc 1941;116:2130-5.   Back to cited text no. 5
6.K, Myrden JA. Verrucous carcinoma of the buccal mucosa in tobacco-chewers; Can Med Assoc J 1960;83:1413-7.  Back to cited text no. 6

Correspondence Address:
C Pravda
Department of Oral Medicine and Radiology, Sathyabama Dental College & Hospital, Chennai
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.90329

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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