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CASE REPORT |
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| Year : 2009 | Volume
: 54
| Issue : 5 | Page : 68-70 |
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| Verrucous carcinoma - report on two cases |
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L Padmavathy, L Lakshmana Rao, N Ethirajan, Kavitha Gunasekaran, B Krishnaswamy
Department of Community Medicine and Pathology, Rajah Muthiah Medical College, Annamalai University, Annamalai Nagar, Chidambaram - 608002, Tamil Nadu, India
Correspondence Address:
L Padmavathy
B3 RSA Complex, Annamalai University, Annamalai Nagar - 608002, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
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 Abstract | | |
Squamous cell carcinoma is a common malignant tumor of the keratinizing cells of the epidermis. Verrucous carcinoma or Ackerman's tumor is a subtype of low grade squamous cell carcinoma that can affect cutaneous and mucous surfaces. Two cases of Verrucous carcinoma affecting the lip and oral mucous membrane (oral florid papillomatosis) are being reported. One patient had a co-existent sub mucous fibrosis, a pre-malignant lesion and two auto-immune disorders, i.e., diabetes mellitus and vitiligo.
Keywords: Ackerman′s tumor, human papilloma virus, oral florid papillomatosis, sub-mucous fibrosis Verrucous carcinoma, tobacco, Vitiligo
How to cite this article:
Padmavathy L, Rao L L, Ethirajan N, Gunasekaran K, Krishnaswamy B. Verrucous carcinoma - report on two cases. Indian J Dermatol 2009;54, Suppl S1:68-70 |
How to cite this URL:
Padmavathy L, Rao L L, Ethirajan N, Gunasekaran K, Krishnaswamy B. Verrucous carcinoma - report on two cases. Indian J Dermatol [serial online] 2009 [cited 2020 Dec 1];54, Suppl S1:68-70. Available from: https://www.e-ijd.org/text.asp?2009/54/5/68/45462 |
| Introduction | |  |
Squamous cell carcinoma is the second most common tumor affecting the skin. Verrucous carcinoma (Ackerman's tumor) is a variant of squamous cell carcinoma that can affect cutaneous and mucosal surfaces. Mucosal lesions involving the oral cavity present as white fungating plaques and are termed oral florid papillomatosis. This tumor is endowed with enough clinical, pathologic and behavioral peculiarities to justify its being regarded as a specific tumor entity. [1],[2],[3]
Verrucous carcinoma is often associated with chronic exposure to Ultra Violet radiation; prolonged use of tobacco, its products and betel nut. The oncogenic viruses HPV16 and 18 are also implicated in the etiology of this condition. [4]
| Case History | | |
Case 1
A 60-year-old male agriculturist presented with an asymptomatic ulcerated verrucous growth on the left angle of the mouth and lower lip of 6 months duration. He had been working in agricultural fields for the past 50 years. He is used to smoking tobacco (8-10 bidis per day) for the past 40 years and is neither a diabetic nor a hypertensive.
On examination, patient had bad oral hygiene with tobacco stained teeth. A verrucous non-tender freely mobile nodule, about 6 cm ´ 5 cm was seen on the lower lip and left angle of mouth, with extension into the buccal mucosa [Figure 1]. There was no cervical lymphnode enlargement. Biopsy from the lesion revealed features of Verrucous carcinoma .
Case 2
A 70-year-old male agriculturist, presented with the complaint of inability to open the mouth for eight months and ulceration on the lower lip for one month. He was a known diabetic, on treatment with oral anti-diabetic drugs with adequate glycemic control. He also had vitiligo for 40 years for which he received oral psoralens twenty years earlier. However, he discontinued treatment with psoralens one year later and tried indigenous medicines for a few months, without much benefit.
Though there was no family history of diabetes, his brother had vitiligo. Our patient was born of a consanguineous marriage.
Patient was a tee-totaler, but was used to chewing tobacco quid and betel (two betel leaves with tobacco, every hour) for the past 30 years.
On examination, a crusted ulcer, 0.5 cm in diameter, with raised edges and a firm base was seen on the lower lip [Figure 2]. Oral hygiene was poor and the patient was unable to open his mouth beyond one finger breadth. The oral mucosa to the extent visualized, showed atrophy and tiny bleeding spots. The cheeks were very firm and indurated. There was no cervical lymphadenopathy. Patient had generalized vitiligo in a symmetrical fashion on lips, axillae, external genitalia, hands and feet. Hair and nails were normal. Other systems were normal clinically.
A provisional diagnosis of sub-mucous fibrosis, vitiligo, diabetes mellitus and squamous cell carcinoma lip was entertained. However HPE of biopsied tissue from the edge of ulcer revealed Verrucous carcinoma [Figure 3].
Both patients were referred to Oromaxillofacial surgery department, where the Verrucous carcinoma tous ulcers were excised with wide margins. For the sub-mucous fibrosis in the second patient, intralesional steroid injections into the buccal mucosa and vitamin E orally, were administered. With the aid of physiotherapy, he was able to open his mouth slightly wider in about four week's time. He was not keen on pursuing treatment for his vitiligo lesions.
Though lesions are known to recur it was not observed in both of our patients.
| Discussion | | |
The lips are the most common site of malignancy in the oral cavity and account for 12% of all head and neck cancers, excluding nonmelanoma skin cancers. Squamous cell carcinoma is the most common histologic type, with 98% involving the lower lip. [5]
Verrucous carcinoma was described by Ackerman in 1948, as a variant of oral carcinoma and was subsequently reported from the penis, vulva, respiratory mucosa and various cutaneous sites. It has been classified as pan-oral involving the oral cavity, esophagus and upper respiratory mucosa (corresponding to "oral florid papillomatosis"), genito-gluteal (earlier described as Bushcke and Lowenstein tumor) and plantar (epithelioma cuniculatum. [6] The course of the tumor is usually indolent with extensive local destruction of tissues. [7],[8],[9]
Verrucous carcinoma comprises of 1-10% of all oral squamous cell carcinomas diagnosed by U.S. hospitals and dental schools. In India, approximately 7% of oral cancers are Verrucous carcinoma s. [10]
The oncogenic viruses HPV-16 and 18 are implicated in the etiology of these conditions. [4] Viral genomic studies could not be undertaken in our patients, due to lack of facilities. In case of tumors involving the vermillion border of the lower lip, actinic radiation is implicated. This area comes into contact with cigars, cigarettes and pipes. All these environmental influences presumably act on a fertile soil, as seen by a number of chromosomal and molecular changes. [11] Ultraviolet B (wavelength 290-320 nm) and Ultraviolet C (wavelength 200-290nm) cause premature aging of the skin and skin cancers. [12] The carcinogenicity of UVB light is attributed to its formation of pyrimidine dimers in DNA. [11] In our patients, chronic actinic radiation in view of their occupation, the prolonged use of tobacco, in addition to bad oral hygiene, could all have been the contributory factors.
In the second patient, other factors like lack of the protective effect of melanin, use of oral psoralens for treatment of vitiligo might also be presumed to have played a facilitatory role. The association of two auto-immune disease i.e., vitiligo and diabetes mellitus is well known. But the co-existence of a pre-malignant condition i.e., submucus fibrosis and a low grade malignancy like Verrucous carcinoma is not often encountered and hence is being reported.
Verrucous carcinoma s carry a high risk of recurrence- up to 40%. [13] Extension to bone is frequent, but nodal metastases are exceptional. [14] However, both patients in our series had no regional lymph node or bone metastases clinically.
As is true with all cancers, early diagnosis is of paramount importance. It is suggested that all lesions that persist for more than three weeks, without a definitive diagnosis need to be biopsied. [4] Aggressive surgical intervention in these cases can result in a good prognosis. The most effective treatment is excision, with Mohs micrographic surgery being required in some cases. [15]
Photodynamic therapy using ALA is a recently tried therapeutic option. In addition, immune therapy involving recruitment of immune cells and administration of stimulatory immune factors to augment the immune response and gene therapy involving a variety of delivery vehicles that can transfer therapeutic genes to target cells are also tried. [5]
| Acknowledgment | | |
Authors thank the authorities for facilities provided for carrying out the work and for permission to publish the article.
| References | | |
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| 12. | Rosen CF. Ultra violet radiation. Pathology of environmental and occupational diseases. In : Craighead JE, editors. St Louis: Mosby Year Book; 1996. p. 193. |
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| 14. | Kao GF, Graham JH, Helwig EB. Carcinoma cuniculatum (verrucous carcinoma of the skin): A clinicopathologic study of 46 cases with ultrastructural observations. Cancer 1982;49:2395-403. |
| 15. | Alam M, Ratner D. Cutaneous squamous cell carcinoma. N Engl J Med 2001;344:975-83. |
[Figure 1], [Figure 2], [Figure 3] |
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