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Verrucous carcinoma - Oral Mucosal Lesion
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Verrucous carcinoma - Oral Mucosal Lesion

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Contributors: Gabriela Ulloa, Loren Krueger MD, Belinda Tan MD, PhD, Susan Burgin MD
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Synopsis

Oral verrucous carcinoma (also known as Ackerman tumor) is a rare, indolent variant of oral squamous cell carcinoma (SCC), representing approximately 5% of SCCs and 3%-4% of all oral carcinomas. Characteristically, oral verrucous carcinomas present as white or pink, painless, velvety lesions or warty exophytic tumors in the oral cavity (buccal mucosa and gingiva), oropharynx, and/or larynx.

Noninvasive verrucous mucosal lesions develop into proliferative verrucous leukoplakia, which can then progress to oral verrucous carcinoma or typical oral SCC.

Verrucous carcinomas rarely metastasize and have favorable prognoses. However, verrucous carcinomas can grow and destroy adjacent tissue, cartilage, and bone if left untreated. Patients usually report being aware of the lesion or tumor for years prior to seeking evaluation by a medical professional.

Men over the age of 55 most commonly develop oral verrucous carcinoma. Women may also develop verrucous carcinoma, but with a different presentation. In a 2001 study, women were reported to have a higher proportion of oral cavity tumors whereas men have higher proportion of laryngeal tumors.

Although most studies report an increased incidence of mucosal verrucous carcinoma among tobacco users (including dry and inhaled tobacco products), 16%-51% of oral verrucous carcinomas have been reported in patients without a history of tobacco use. When tobacco use is present and verrucous carcinoma is suspected, the mandibular vestibule (placement site for dry tobacco), buccal mucosa, hard palate, oropharynx, and larynx should be carefully inspected.

Human papillomavirus (HPV) has not been proven to be associated with oral verrucous carcinoma despite HPV having a proven role in many other verrucous conditions and verrucous carcinomas in other locations.

Codes

ICD10CM:
C44.320 – Squamous cell carcinoma of skin of unspecified parts of face
D04.9 – Carcinoma in situ of skin, unspecified

SNOMEDCT:
89906000 – Verrucous Carcinoma

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Squamous cell carcinoma – SCCs are more common on lateral tongue, floor of mouth, and lateral soft palate. SCCs are often ulcerated and may be endophytic. Ki67 (proliferative marker) and mutated p53 (tumor suppressor gene) are present throughout the biopsy of SCC rather than the lower one-third or the basal layer of verrucous carcinomas. Approximately 20%-25% of excised specimens of verrucous carcinoma have foci of conventional SCC.
  • Verrucous hyperplasia (including verrucous leukoplakia and dysplasia) – Benign verrucous hyperplastic lesions that clinically and histologically resemble verrucous carcinoma. Alpha smooth muscle actin (α-SMA) reactivity can help differentiate this from verrucous carcinoma since verrucous hyperplastic lesions show no α-SMA reactivity, while approximately 93% of verrucous carcinomas are α-SMA reactive.
  • Proliferative verrucous leukoplakia – This unusual preneoplastic process presents as multiple keratotic and verrucous plaques involving the buccal mucosa, tongue, and/or palate. There is a strong female predilection and minimal association with tobacco use. Over decades, this may transform into verrucous carcinoma or SCC.
  • Condyloma acuminatum – Lesions may appear confluent, mimicking verrucous carcinoma. Generally, oral condyloma appears in a younger age group compared to verrucous carcinoma. Many patients with condyloma acuminatum are immunocompromised.
  • Focal epithelial hyperplasia (Heck disease)

Best Tests

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Management Pearls

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Therapy

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References

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Last Reviewed: 01/18/2018
Last Updated: 01/31/2018
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Verrucous carcinoma - Oral Mucosal Lesion
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Verrucous carcinoma (Skin) : Skin ulcer, Verrucous scaly papule, Verrucous scaly plaque
Clinical image of Verrucous carcinoma
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