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Verrucous carcinoma (VC) is a distinct, well-differentiated variant of oral squamous cell carcinoma characterized by slow growth, minimal cytologic atypia, and a locally aggressive but non-metastasizing behavior. Although it carries a favorable prognosis compared with conventional Oral Squamous Cell Carcinoma (OSCC), misdiagnosis and inappropriate management can result in significant morbidity. Dental professionals play a critical role in its early recognition and diagnosis.
Definition and Classification
Verrucous carcinoma is a low-grade squamous cell carcinoma first described by Ackerman in 1948, often referred to as Ackerman’s tumor. It is classified as a variant of OSCC by the World Health Organization and is distinguished by its exophytic, warty appearance and pushing (rather than infiltrative) pattern of growth.
Epidemiology and Risk Factors
Verrucous carcinoma primarily affects older adults, with a male predominance. It is strongly associated with chronic exposure to carcinogens.
Major risk factors include:
- Smokeless tobacco use (snuff, chewing tobacco)- Betel quid and areca nut chewing
- Chronic smoking
- Poor oral hygiene and chronic mucosal irritation
- Possible association with HPV (role remains controversial)
VC is more prevalent in regions where areca nut and smokeless tobacco use are endemic.
Common Sites of Involvement
The oral cavity is the most frequent site of verrucous carcinoma, particularly:
- Buccal mucosa- Gingiva and alveolar ridge
- Hard palate
- Tongue
- Floor of the mouth
Extraoral sites include the larynx, esophagus, and anogenital region.
Clinical Presentation
Clinically, verrucous carcinoma presents as a:
- Slow-growing, painless lesion- Broad-based, exophytic mass with a verrucous or papillomatous surface
-White, gray, or erythematous lesion with deep clefts or fissures
- Firm, well-demarcated lesion often mistaken for benign hyperkeratotic conditions
Because of its indolent nature and benign appearance, diagnosis is frequently delayed.
Differential Diagnosis
The clinical differential diagnosis includes:
- Verrucous hyperplasia- Proliferative verrucous leukoplakia
- Conventional OSCC
- Squamous papilloma
- Chronic hyperplastic candidiasis
Accurate differentiation is critical, as treatment strategies differ significantly.
Diagnostic Considerations
Histopathological examination is essential for diagnosis. A key diagnostic challenge is that superficial or inadequate biopsies may miss diagnostic features, leading to underdiagnosis.
Recommended diagnostic approach:
- Deep incisional biopsy including adjacent normal tissue- Multiple biopsies in large or heterogeneous lesions
- Correlation of clinical and histologic findings
Histopathological Features
Characteristic microscopic features include:
- Well-differentiated squamous epithelium- Broad, bulbous rete ridges with a “pushing” border
- Minimal cytologic atypia
- Abundant keratin production
- Absence of deep stromal invasion and metastasis
Lymph node involvement is exceedingly rare unless a hybrid lesion with conventional OSCC is present.
Management and Treatment
Surgical excision with adequate margins is the treatment of choice for oral verrucous carcinoma.
Key management principles:
- Wide local excision- Avoidance of radiotherapy as primary treatment (risk of anaplastic transformation has been reported)
- Regular long-term follow-up due to risk of recurrence or coexistence with conventional OSCC
Neck dissection is generally not indicated unless clinical or histological evidence of invasive carcinoma exists.
Prognosis
Verrucous carcinoma has an excellent prognosis when adequately treated:
- High survival rates- Low recurrence if completely excised
- Minimal risk of metastasis
However, recurrence can occur if excision is incomplete or if field cancerization persists due to continued exposure to risk factors.
Role of Dental Professionals and Students
Dental practitioners are often the first clinicians to encounter verrucous carcinoma. Their role includes:
- Early identification of suspicious verrucous lesions- Recognition of lesions unresponsive to conventional therapy
- Ensuring appropriate biopsy technique
- Patient education on tobacco and areca nut cessation
- Long-term surveillance of high-risk patients
For students, understanding VC reinforces the importance of correlating clinical appearance with histopathological findings and maintaining a high index of suspicion for atypical lesions.
Conclusion
Verrucous carcinoma is a unique clinicopathologic entity that occupies an important position within the spectrum of oral epithelial malignancies. Although it exhibits low-grade malignant behavior, delayed diagnosis or inadequate treatment can lead to extensive local destruction. For dental and medical professionals, early recognition, proper biopsy, and definitive surgical management are essential to ensuring favorable outcomes.