Verrucous Carcinoma of Buccal Mucosa in Female: A Rare Case Report of Traumatic Tooth Origin
V. Keerthi Narayan
Department of Oral Pathology and Microbiology, Thai Moogambigai Dental College and Hospital, Dr. MGR Educational and Research Institute, 600107, Chennai, Tamil Nadu, India
Correspondence should be addressed to V. Keerthi Narayan; firstname.lastname@example.org Received 7 December 2020; Revised 14 May 2021; Accepted 27 May 2021; Published 12 June 2021 Academic Editor: Giovanni Mergoni
Copyright © 2021 V. Keerthi Narayan. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Verrucous carcinoma or Ackermann’s tumor is considered a low-grade variant of squamous cell carcinoma frequently presenting at the oral mucosa and skin. Oral verrucous carcinoma clinically presents as a proliferative or cauliﬂower-like lesion or as ulceroproliferative lesion on the buccal mucosa followed by other sites such as the gingiva, tongue, and hard palate. Tobacco in both smoking and smokeless form, alcohol, and opportunist viral infections are the most associated etiologies in most of the reported literature cases. Here, in this paper, we discuss a rare case scenario of a 52-year-old female diagnosed with verrucous carcinoma of the left buccal mucosa with constant traumatic irritation caused by tooth as etiology for the occurrence of lesion, though verrucous carcinoma is described as a benign lesion with minimum aggressive potential but long-standing cases have shown transformation into squamous cell carcinoma. Therefore, early diagnosis and surgical excision of the lesion are the most appropriate treatment modality of verrucous carcinoma.
Cancer of the head and neck region is of signiﬁcant public health importance in India. Most often, it is diagnosed at advanced or late stages resulting in extremely low and poor treatment outcomes with considerable ﬁnancial constrain . Oral cancer often manifests itself in about 45%-48% of cases as ulcers or ulcerated tumors. Owing to its wide range of causative factors and unpredictable presenting features, the diagnosis of oral ulcerative lesions might be quite chal- lenging. In initial cases, these carcinomatous ulcers can be confused with other pathological entities and often misdiag- nosed as nonneoplastic ulcerative lesion. Such lesions lasting for two weeks or longer often create a dilemma due to its chronicity and unresponsive behaviour to various treatments prescribed .
In order to arrive at a deﬁnitive diagnosis, earlier detec- tion of oral cancer followed by laboratory tests and additional investigations to narrow the diagnosis oﬀers the best chance for long term survival and has the potential to improve treat-
ment outcomes and make healthcare services aﬀordable [3–
5]. In this paper, we discussed an unusual presentation of verrucous carcinoma (VC) of the buccal mucosa in a female patient with rapid progression of the disease even after the removal of etiological agent suggesting a new variation in a disease process. In addition to this unfamiliar etiological fac- tor and course of the disease, theseﬁndings could shed new light on the possible pathogenesis of verrucous carcinoma.
2. Case Report
2.1. About the Case. A 52-year-old female patient visited the Outpatient Department of Our Dental College and Hospital with a chief complaint of a nonhealing ulcerated tissue on the left lower back tooth region for the past 6 months, asso- ciated with pain and burning sensation during intake of spicy or hot food items occasionally. She developed continuous severe burning sensation accompanied by pain since 1 week in the same region. No relevant past medical, dental,
Volume 2021, Article ID 6673038, 5 pages https://doi.org/10.1155/2021/6673038
occupational, and habit history was observed in relation with the chief complaint.
2.2. On Intraoral Examination
2.2.1. Visit 1. On soft tissue examination, a solitary, ﬁrm, ulcerative tissue measuring2 × 2 centimetres was found on the alveolar mucosa near premolar region separated from it by clinically healthy mucosa. On stretching the cheek mucosa, a tooth root was found extruding from the socket impinging on the soft tissue counterpart surrounding areas (Figures 1 and 2). No other lesions were observed on either side of the oral mucosa. After comprehensive intraoral exam- ination followed by analysis of the past dental and relevant history, an interim diagnosis of traumatic ulcer was given in association with the tooth as the source of origin. Patient consent was obtained before proceeding with the treatment.
Extraction of the tooth root was performed under local anaesthesia (Figure 3). The procedure was uneventful, and postoperative instructions were given for the same. The patient was normal and freed of complaints during postoper- ative follow-up made after 15days.
2.2.2. Visit 2. The patient reported again to the outpatient department with similar complaints of pain and severe burn- ing sensation after 3 months in the same region. On intraoral examination, nodular proliferous ulcerative growth measur- ing3 × 2 centimetres was found on the alveolar mucosa near the premolar-molar region with focal areas of white spots (Figure 4). She was referred immediately to our oral pathol- ogy department followed by prescription of topical applica- tion of antiviral drugs (2% acyclovir) for a week. As the lesion did not show signs of regression, routine blood inves- tigations were carried out to rule out complications following biopsy and were found to be normal. An incisional biopsy was advised for the same with diﬀerential diagnosis of focal epithelial hyperplasia; traumaticﬁbroma, verruciform leuko- plakia, verruca vulgaris, verrucous carcinoma, and ulcerative squamous cell carcinoma were suggested.
2.3. Histopathological Analysis. Histopathological analysis showed a broad bulbous rete pegs with pushing margins in many areas along with features of mild dysplasia and few areas of parakeratin plugging. There were also few areas of severe dysplasia without signiﬁcant break in the basement membrane and malignant cells inﬁltrating into the subjacent minimal connective tissue stroma with inﬂammatory cells which led to a provisional diagnosis of verrucous carcinoma of buccal mucosa.
2.4. Diﬀerential Diagnosis and Its Consideration. Verrucous carcinoma has particular clinical and histopathological fea- tures that agree its diagnosis to be obtained, which was an uncharacteristic observation in the present case. First, the clinical reasons for rejection were considered followed by the histological ones for each diagnosis, to obtain aﬁnal diag- nosis thus clearly separating from others. Oral traumatic ﬁbroma was ruled out since it presents as a ﬁrm smooth pap- ule in the mouth, usually the same colour as the rest of the mouth lining, but is sometimes paler or, if it has bled, may
look a dark colour. The surface may be ulcerated due to trauma or become rough and scaly. It is usually dome- shaped but may be on a short stalk like a polyp or peduncu- lated . It should be noted no histological dysplastic fea- tures and other observations are not present and ﬁbromas Figure 1: Clinical photograph showing a solitary, ﬁrm, ulcerative tissue measuring 2 × 2 centimetres on the alveolar mucosa near the premolar region.
Figure 2: Clinical photograph showing the stretching of the cheek mucosa a tooth root found extruding from the socket impinging on the soft tissue counterpart surrounding areas.
Figure 3: Clinical photograph showing a completely removed tooth under local anaesthesia.
never develop into oral cancer, similarly verrucous hyperpla- sia (VH) are often associated with papillomas or arise as a de novo lesion. VH (verrucous hyperplasia) and PVL (Prolifer- ative Verrucous Leukoplakia) are irreversible clinicopatho- logic lesions with considerable potential for evolving into verrucous or squamous cell carcinoma. PVL is a disease of the oral cavity in which VH is a part of its developmental spectrum. Human papillomavirus, as a cofactor, may play an important role in some of these lesions [7, 8]; however, no signs suggestive of HPV infection were observed in the present histopathology section.
2.5. Treatment and Follow-Up. In the present case, as no other ﬁndings like nodal involvement or metastasis were observed, clinical staging of T2N0M0 was given. A wide local surgical excision was planned and performed under local anaesthesia (Figure 5). To ensure complete removal of the lesion with clear margins, further examination of the com- plete surgical specimen was sent for histopathological inves- tigation and also to rule out inﬁltrating squamous cell carcinoma. The procedure was uneventful, and postoperative instructions were given. A postoperative follow-up was performed at an interval of every 15 days over a period of 3 months. No further complaints were observed.
2.6. Final Diagnosis. In this instance, though varied clinical course of the disease was noted, the histological result of the complete surgical specimen showed features of verru- cous carcinoma similar to the reports obtained during the incisional biopsy thus ruling out squamous cell carcinoma evolved from a verrucous carcinoma (Figure 6). Thus, on complete evaluation of clinical and histological ﬁndings, a conclusive diagnosis of verrucous carcinoma (VC) was given.
Verrucous carcinoma (VC) is a rare, low-grade, well- diﬀerentiated SCC of the skin or mucosa presenting with a verrucoid or cauliﬂower-like presence. It shows in the vicin- ity aggressive behaviour and has low metastatic potential, a low grade of dysplasia, and a good prognosis. It is a tumor that tends to erode more than inﬁltrate with predominantly
horizontal growth and does not present with distant metasta- sis. It has been presented with various names such as Ackerman tumor and carcinoma cuniculatum which are correlated to speciﬁc anatomic sites [9, 10].
In the oral cavity, verrucous carcinoma constitutes 2% to 4.5% of all forms of SCC seen mainly in men older than 50 years and also is associated with a high incidence (37.7%) of a second primary tumor mainly in the oral mucosa (e.g., tongue, lips, palate, and salivary gland) . Kalsotra et al.
reported a male to female ratio of 3.6 to 1 in patients with verrucous carcinoma, with a mean age of 53.9 years. In the present report of a case, it is seen with female older than 50 years though it is thought to predominantly aﬀect elderly men . The etiology of VC is related to various local and systemic sources such as Human Papilloma virus and chemi- cals from cigarettes (smoking) or physical source such as constant trauma and irritation [13, 14]. In this case, the patient did not present with most common factors like tobacco, alcohol consumption, or any occupational factors but presented with history of irritation to the buccal mucosa by tooth.
Figure 4: Clinical photograph showing nodular proliferous ulcerative growth measuring3 × 2 centimetres on the alveolar mucosa.
Figure 5: Clinical image showing a wide local surgical excision performed under local anaesthesia.
Figure 6: Histopathology of completely excised specimen showed verrucous conﬁguration with a broad bulbous rete pegs with pushing margins in many areas along with features of mild dysplasia and few areas of parakeratin plugging (H&E, original magniﬁcation: ×40).
However, epidemiological studies generally analyse the relationship between chronic traumas of the oral mucosa originated by dentures and cancer, but mostly, they do not include other traumatic factors such as defective teeth or parafunctional habits, and they do not analyse the relation- ship between dental factors and oral potentially malignant disorders (OPMD). Although faulty restorations, sharp teeth, and ill-ﬁtting dentures have been implicated in a few epidemiological studies, it is not clear whether confounding factors like tobacco and alcohol have been addressed in these studies [15, 16].
Valente et al. , Tornes et al. , and Rahali et al. 
reported few cases of squamous cell carcinoma misdiagnosed as a denture-related traumatic ulcer. Meanwhile, de Sant’Ana dos Santos et al. reported misdiagnosis of lip SCC as actinic cheilitis . A case of gingival SCC masquerading as an aphthous ulcer was also reported by Kumari et al. This time elapse might jeopardize patients’ overall prognosis; therefore, attempts should be done for timely diagnosis by more logical routes such as decision trees rather than test-and-error methods . The present case scenario admits the fact that other traumatic factors such as sharp teeth or defective teeth are a possible agent for arising of lesion but the primary eti- ology of trauma as a true etiological factor has to be analysed further by investigation on a larger scale by reporting of var- ious cases across the world.
Histopathologically, VC frequently presents with a hyperplastic epithelium with abundant keratin superﬁcially projecting as exophytic church-spire keratosis with bulbous well-oriented rete ridges shows an endophytic growth pat- tern with pushing borders. Rapid transition from a normal epithelium to endophytic ingrowth is taken as a signiﬁcant feature to diﬀerentiate it from benign verrucous growths . A classic case of VC shows minimal or no pleomor- phism of cells, and no mitotic activity above the basal and suprabasal layers of the epithelium and lymphoplasmacytic inﬂammatory host reaction are marked, especially in cases where keratin has plunged deep into the connective tissue inducing foreign body granuloma formation as not seen or appreciated in the present case. Insuﬃcient depth of the sec- tion, the absence of adjacent normal epithelium, presence of dysplastic features, and evidence of micro invasion create a dilemma for the pathologist. To avoid such scenario, deeper sections were taken and conclusive evidences were consid- ered as it becomes mandatory to rule out SCC [22, 23].
Among various therapeutic approaches, surgical inter- vention is the primary therapeutic mode to treat verrucous carcinoma. Surgical excision with adequate margins has been proven to be eﬀective in the management of these tumors, and radiotherapy has generally been recommended in the presence of adverse risk factors in the histopathology report such as metastatic lymph node positivity and invasion to the deeper vital structures like nerves and blood vessels [24, 25]. In the present case as no other ﬁndings like nodal involvement or metastasis was observed, clinical stating of T2N0M0 was given. Only surgical intervention for complete removal of tumor by intraoral approach was recommended since it may not be eﬀective as in the case of larger area exten- sion of the carcinogenic lesion.
In the present case, an unexpected or unusual demonstration of verrucous carcinoma caused by local irritation in the form of tooth, with rapid progression of the disease lesser than the usual demonstration even after removal of the etiological agent, suggests a new variation in a disease process. VC should be considered in the diﬀerential diagnosis of slow growing ulcerative lesion though not characteristic as noted in the present case considering the evolving epidemiological and etiopathological trends and in addition to the fact that theseﬁndings could shed new light on the possible pathogen- esis of verrucous carcinoma. In this case, proper diagnosis was made as early as possible to avoid further complication and was appropriately treated. Thus, both clinicians and pathologists must be cautious about chronic traumatic ulcers or ulcerative lesions of the oral cavity and propose diagnostic alternatives to ensure the most appropriate treatment to be given at the right time.
Conflicts of Interest
None is declared.
The study was self-funded by the author.
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