Hybrid Verrucous Squamous Carcinoma of the Oral Cavity: Treatment Considerations Based on a Critical Review of the Literature

Atypical Squamous Verrucous Lesions of the Oral Cavity: Challenges in Interpretation of Small Incisional Biopsies

BACKGROUND

Squamous verrucous proliferative lesions of oral cavity can pose a diagnostic challenge for the general pathologist, especially on small biopsies. The superficial nature of incisional biopsies and inconsistent histologic terminologies used for these lesions contribute to often-discrepant clinical diagnosis, resulting in delayed treatment. This study aims to explore the proliferative squamous lesions of oral cavity, correlate biopsy & resection diagnoses, and evaluate possible reasons for discrepant diagnosis (if any).

DESIGN

A retrospective review of oral verrucous squamous lesions was undertaken. Pathology database was searched for oral cavity biopsies from January2018 through August2022 with the keywords: atypical, verrucous, squamous, and proliferative. Cases with follow-up were included in this study. A blinded review of the biopsy slides was performed and documented by a single head and neck pathologist. Demographic data, biopsy and final diagnosis were recorded.

RESULTS

Twenty-three cases met criteria for inclusion. The mean patient age was 61.1 years with a male: female ratio of 1.09. Most frequent site was lateral border of tongue (36%) followed by buccal mucosa and retromolar trigone. The most common biopsy diagnosis was "Atypical squamoproliferative lesion, excision recommended" (n = 16/23, 69%) with 13/16 showing conventional squamous cell carcinoma (SCC) on follow-up resection. 2/16 atypical cases underwent repeat biopsy for confirmation of diagnosis. Overall, conventional SCC was the most prevalent final diagnosis (73%, n = 17), followed by verrucous carcinoma (17%, n = 4). On slide review, six initial biopsies were reclassified as SCC, while one final diagnosis was reclassified as a hybrid carcinoma (on resection specimen). Diagnostic concordance (biopsy and resection) was observed in three cases, all three were recurrences. The primary reasons for discrepant diagnosis on initial biopsies were found to be 1. Obscuring inflammation, 2. Superficial biopsies, and 3. Under recognition of morphologic features (e.g., tear shaped rete, loss of polarity, dyskeratotic cells, paradoxical maturation) that help differentiate dysplasia from reactive atypia.

CONCLUSION

This study highlights the rampant interobserver variability in diagnosis of oral cavity squamous lesions and emphasizes importance of identifying morphologic clues that can aid in correct diagnosis, thereby helping in adequate clinical management.

A Rare Case of Verrucous Carcinoma and Trichoblastoma of the Neck: A Case Report and Literature Review

Verrucous carcinoma (VC) is a variant of cutaneous squamous cell carcinoma. This phenomenon mainly affects the oropharynx, genitalia, and soles of the feet. VC is a well-defined, exophytic, cauliflower-like growth that is warty in nature. Trichoblastoma is a benign epithelial tumor composed of follicular germinative cells. It presents as a small, smooth, non-ulcerated, skin-colored nodule on the scalp, neck, thigh, and perianal regions. The dual presentation of verrucous carcinoma and trichoblastoma of the neck is rare. Though treatment can be achieved through surgical resection, early detection offers a good prognosis. We present the case of a 54-year-old homeless male who presented with an unusual neck mass that was initially misidentified as an abscess. Surgical debridement was performed, and histopathological analysis revealed the presence of a rare combination of VC and trichoblastoma. This report highlights the challenges of this rare presentation, which may be overlooked or misdiagnosed as an abscess.

Surgical treatment of verrucous carcinoma: a review

BACKGROUND

Verrucous carcinoma is a rare mucocutaneous malignancy characterized by slow, relentless growth and a low metastasis rate.

OBJECTIVE

Herein we summarize surgical success rates and review newer approaches to the treatment of verrucous carcinomas.Methods & Materials: PubMed electronic searches were performed by B.F. and C.V. using combinations of the following terms: ''verrucous carcinoma,'' ''Ackerman tumor,'' ''Buschke Lowenstein,'' ''epithelioma cuniculatum,'' ''carcinoma cuniculatum,'' ''papillomatosis cutis,'' ''treatment,'' ''therapeutics,'' ''management,'' ''mohs surgery,'' and ''excision.'' A systematic review was conducted on 49 articles in accordance with PRISMA guidelines.

RESULTS

Surgical management remains first-line therapy. Wide local excision is most commonly utilized, with highly variable margins (0.5-3.0 cm) and recurrence rates (4.6-75.0%). Mohs Micrographic Surgery has also been used, especially for recurrent tumors, with an overall recurrence rate of 12.9%.

CONCLUSION

Surgery is the treatment of choice, either by Mohs Micrographic Surgery or wide local excision. However, surgical recurrence rates are high, and tissue-sparing therapies are desirable given the sensitive locations involved. Ultimately, randomized control trials are needed to develop evidence-based guidelines for the management of VCs.

Detection of Micro-invasion in Sudanese Oral Verrucous Carcinoma Samples Using Syndecan-1 Stain

Aim:

Verrucous carcinoma (VC) is a low-grade rare variant of squamous cell carcinoma (SCC). Syndecan-1 (CD138) is a heparan sulfate proteoglycan which participates in cell-to-cell adhesion and cell-matrix interaction. Being misled by the apparent non-aggressive nature of VC, some clinicians and pathologists believe that this tumor is not an aggressive tumor, not realizing the fact that some of these lesions may contain nests or foci of well-differentiated SCC. This study aimed to assess syndecan-1 expression of VC and detection of micro-invasion in VC using syndecan-1 immunohistochemical (IHC) stain.

Methods:

Observational analytical study of 34 paraffin block of VC cases and 24 cases of variable grades of oral epithelial dysplasia. Cases were stained by hematoxylin and eosin (H&E) and then IHC stain for syndecan-1 was applied. Nine paraffin blocks from specimens of normal oral mucosa were used as the reference group for syndecan-1 stain positivity.

Results:

In this study, we found that 32 (94.1%) out of 34 of verrucous carcinoma cases showed loss of syndecan-1 expression. Moreover, highly statistically significant association was found between the presence of suggestive micro-invasion in H&E and loss of syndecan-1 expression in micro-invasive area in the same case.

Conclusions:

In conclusion, syndecan-1 stain can be used as a biomarker in detection of micro-invasion in verrucous carcinoma.

Oral verrucous carcinoma: From multifactorial etiology to diverse treatment regimens (Review)

Oral verrucous carcinoma (OVC) is a verrucous variant of oral squamous cell carcinoma (OSCC), which accounts for 2-12% of all oral carcinomas with a 5-year survival rate of only approximately 50%. Enormous effort has been dedicated to this cancer, and the past decades have witnessed significant advances in relevant diagnostic and therapeutic approaches. Currently, there exist three challenges from primary sub-fields of research and clinical practice of the cancer, namely multifactorial etiology, complex molecular mechanism, and deficient treatment. This study reviews the existing literature on the cancer, encompassing its etiology, clinical manifestations and pathology, molecular mechanism, diagnosis and differential diagnosis, and treatment. For improved treatment of OVC, multifactorial etiology analysis, incorporation of effective biomarkers for mechanism illustration, and integration of multidisciplinary modalities are expounded, in an attempt to resolve the challenges and to provide a useful guide for future research in the field.

Verrucous carcinoma of the oral mucosa: an epidemiological and follow-up study of patients treated with surgery in 5 last years

INTRODUCTION

Oral Verrucous Carcinoma (OVC) is described apart of the Squamous Cell Carcinoma (SCC) due to its specific properties. The objective of our study is to show our series of cases of OVC and to compare with the SCC in terms of clinical manifestations, epidemiology, histopathology, treatment and follow-up.

MATERIAL AND METHODS

This is a retrospective study of all the OVC treated in our department between January-2007 and December-2011. The analyzed variables were sex, age, localization in the oral cavity, histopathology, number of biopsies needed to diagnose OVC, TNM classification, treatment and recurrences during follow-up.

RESULTS

Our sample was composed by n=14 patients, 57% female, with a mean age of 69.14 years. The most common localization was buccal mucosa (n=5). Seven patients were diagnosed of OVC with the first biopsy. TNM classification was: pT1: 7 patients, pT2: 3 patients, pT3: 3 patients, pT4: 1 patient. No cervical metastases were observed either in cervical neck dissection or during the follow-up of the patients. The treatment was surgery with clinical resection margins up to 1 cm in all cases, followed by radiotherapy in selected cases. Only n=1 patient (7.69%) presented a recurrence after 34 months of follow-up. The overall survival rate was 92.85%.

CONCLUSIONS

In our population, OVC represents the 6.16% of all oral cavity and oropharynx cancer, and is more frequent in female patients above 70 years old. It uses to rise over a previous lesion, and usually affects the buccal mucosa. In patients with high suspicious lesions, more than one biopsy may be needed to diagnose OVC. No patient showed cervical dissemination. In our experience, treatment based on local resection, without cervical neck dissection, could be a good option for these patients.

Verrucous carcinoma with dysplasia or minimal invasion: a variant of verrucous carcinoma with extremely favorable prognosis

Verrucous carcinomas (VC) recur locally but do not metastasize in the absence of an invasive squamous cell carcinoma (SCC) component. Although excluded from the definition of pure VC, some tumors harbor only dysplasia or minimal invasion, findings of unknown clinical significance. Surgically resected VC cases from two institutions were collected and categorized into three types: VC, VC with dysplasia or minimal invasion (VCDMI), defined as SCC less than or equal to 2 mm in depth, and SCC arising in VC (SCC-VC) where the SCC was greater than 2 mm in depth. Cases were also matched with conventional SCC based on location and T and N-stages, and clinical follow up was obtained. Of the 58 total cases, 18 were VC, 26 VCDMI, and 14 SCC-VC. Only 1 of 18 (5.6 %) VC and 5 of 26 (19.2 %) VCDMI cases recurred locally (p = 0.37) versus 7 of 14 (50 %) SCC-VC (p = 0.01). All VC and VCDMI cases were node negative at presentation whereas SCC-VC had nodal metastases in 2 of 14 (14.3 %) cases. No patients with VC or VCDMI died from disease, whereas 5 of 14 (35.7 %) patients with SCC-VC died from disease. T-stage matched conventional SCC cases from institutional databases had worse outcomes than VC and VCDMI, but not after they were matched for both T and N-stages. Our findings suggest that dysplasia and/or minimal invasive SCC do not adversely affect outcomes in tumors otherwise showing diagnostic features of VC.

Subset of patients with verrucous carcinoma of the oral cavity who benefit from treatment with methotrexate

Oral verrucous carcinoma (OVC) is a low-grade variant of squamous cell carcinoma (SCC) with a distinctive morphology and specific pattern of behaviour that is often diagnosed in elderly patients. Resection is the treatment of choice, with radiotherapy as a reasonable alternative. In this retrospective case review we present our experience and outcomes in a group of 12 patients with various stages of OVC who had not been treated conventionally because of the extent of their lesions and their poor general condition. All patients were given chemotherapy with methotrexate, which was given by various routes and in different doses during the period 1972-2010. In 11 patients treatment with methotrexate alone was beneficial. One patient failed to respond. Methotrexate used alone as chemotherapy may minimise morbidity and improve quality of life, particularly among elderly patients.