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

Evaluation of VEGF, BDNF, TRKB expression in oral epithelial dysplasia, oral verrucous carcinoma and oral squamous cell carcinoma and their role as prognostic indicator

BACKGROUND

Oral squamous cell carcinoma (OSCC) is a serious health disease that can lead to a reduced quality of life or even death. It ranks sixth in terms of cancer expansion. It is one of India's primary causes of natural death. In OSCC such potentially malignant Disorders (PMDs) are precancerous lesions with such a high risk of progression. Tumor angiogenesis is a one of the basic biomarkers that may influence the proliferation of a precancerous lesion into the cancerous lesion. Tropomyosin receptor kinase B (TrkB), vascular endothelial growth factor (VEGF), and brain-derived neurotrophic factor (BDNF) also play important roles in carcinogenesis by promoting angiogenesis. The construction of new vessels of blood from existing vasculature is referred as angiogenesis.

AIM OF THE STUDY

To get deep insights of immunohistochemistry expression of VEGF, BDNF, and TRKB in oral epithelial dysplasia (OED), verrucous carcinoma (VC), and OSCC.

MATERIAL AND METHODS

The study included 100 formalin-fixed paraffin-embedded tissue blocks from 20 cases of OED, 20 cases of VC, and 60 cases of OSCC [20 cases of well-differentiated oral squamous cell carcinoma (WD-OSCC), 20 cases of moderately differentiated oral squamous cell carcinoma (MD-OSCC), and 20 cases of poorly differentiated oral squamous cell carcinoma (PD-OSCC). The staining intensity and distribution of VEGF, BNDF, and TrkB were examined and statistically analyzed using analysis of variance (ANOVA), post hoc Bonferroni test, independent t-test, Pearson's Chi-square test, and Pearson's correlation coefficient test.

RESULTS

The immunoexpression of VEGF, BDNF, and TrkB was found to be elevated in the order of OEDs, VC, and OSCC. The percentage of positive was highest in PD-OSCC, followed by MD-OSCC and WD-OSCC.

CONCLUSION

Based on our findings, angiogenesis plays a significant role in tumor growth and metastasis. A substantial relationship was discovered between VEGF, BDNF, TrkB expression, and increases in vascularity throughout the transition from OEDs to VCs and OSCCs.

Comparison of the 7th and revised 8th UICC editions (2020) for oral squamous cell carcinoma: How does the reclassification impact staging and survival?

Since its introduction in 1968, the TNM (tumor, node, metastasis) classification established by the International Union Against Cancer has provided a consistent framework for staging of oral squamous cell carcinoma (OSCC). The introduction of the 8th edition in 2017 brought about significant modifications, encompassing the integration of depth of invasion (DOI) and extranodal extension (ENE) into the T and N classifications. Further, the UICC the criteria for the T3 and T4a categories were amended in 2020. This study aimed to evaluate the impact of reclassification on staging and, subsequently, the survival of patients with OSCC. Primary OSCCs from 391 patients were classified according to the 7th and revised 8th UICC editions (2020). Stage migration was assessed, and stage-specific progression-free survival (PFS) and overall survival (OS) were evaluated using the Kaplan-Meier method. The log-rank test was used to compare the different stages. Cox-proportional hazard modeling was used to compare the two editions. Incorporating the DOI into the T classification resulted in an upstaging of 77 patients, constituting 19.69% of the cohort. In addition, 49 (12.53%) patients experienced an upstaging when considering ENE in the N classification. Consequently, 103 patients underwent upstaging in UICC staging, accounting for 21.74% of cases. Upstaging mainly occurred from stage III to IVA (26.92%) and from stage IVA to IVB (31.78%). Upon comparing the categories in survival analysis, significant differences in OS and PFS were especially observed between stage IVB and lower stages. When examining the hazard ratios, it became evident that UICC 8 stage IVB is burdened by a 5.59-fold greater risk of disease progression than stage I. Furthermore, UICC 8 stage IVB exhibits a 3.83 times higher likelihood of death than stage I disease. We demonstrated significant stage migration from the 7th to the revised 8th UICC edition. Overall, incorporating DOI and ENE into the T and N classifications represents a substantial clinical advancement, leading to a more accurate staging of OSCC patients. Both staging systems exhibited statistically significant discrimination between stages; however, the 8th UICC edition allowed for a more precise categorization of patients based on their prognosis and led to enhanced hazard discrimination, particularly within higher stages.

Reconstructive surgery and adjuvant radiotherapy for the multimodal approach in oral cancer: a single cancer centre experience

Introduction and importance

Ablative surgery for oral cancer, irrespective of the histological subtype, causes large tissue defects, functional and aesthetic damage. Microsurgical free flaps have been widely used in reconstruction after resection, with satisfactory success rates in conjunction with adjuvant radiotherapy (RT). This study aims to describe our clinical institutional experience based on the multimodal treatment performed in four cases diagnosed with oral squamous cell carcinoma with the use of different microvascular free flaps and RT.

Case series presentation

Four patients underwent reconstructive microsurgery after surgical resection of oral cancer, using three types of free flap: radial forearm fasciocutaneous, osteomyocutaneous fibular, and anterolateral thigh musculocutaneous flaps; RT was performed in Case 2 and Case 3. In the period of 3 years after microsurgical reconstruction and RT, flaps remain clinically stable without failure signs in full patients submitted to multimodal treatment.

Clinical discussion

After resection of oral carcinomas, extensive tissue defects can be successfully treated with reconstructive microsurgery using different types of microvascular free flaps. RT for locoregional control is a feasible option and did not seem to interfere with the survival of flaps.

Conclusion

An enhance long-term follow-up to assess overall and disease-free survival rates and quality of life must be carried out; however, cohort studies would be necessary for better understanding of the role of each treatment in the multimodal scheme.

Oral verrucous Carcinoma on mandibular right alveolar region

Verrucous carcinoma, a low-grade variant of squamous cell carcinoma, defined as a diagnostically squamous cell neoplasia involving lip, oropharyngeal, and laryngeal mucosa and named as 'Ackerman's tumour' by Ackerman in 1948. It usually occurs in the lower lip region and this is one such case in which a painful proliferative growth was evident over the right alveolar region for the period of 8 months. Radiological investigations, biopsies were performed followed by surgical excision of the lesion.

Oral verrucous carcinoma: a diagnostic and therapeutic challenge

BACKGROUND

Verrucous carcinoma is a low-grade variant of squamous cell carcinoma with specific morphologic, cytokinetic and clinical features. Despite low mitotic activity and slow growth, it can infiltrate adjacent tissues in advanced stages but does not metastasize. The most frequently affected site is the oral cavity. The following article provides latest updates in the etiology, clinical presentation, diagnostics and treatment options in oral verrucous carcinoma and discusses the existing dilemmas linked to this unique malignancy.

CONCLUSIONS

Oral verrucous carcinoma must be differentiated from conventional squamous cell carcinoma due to its less aggressive behaviour with a more favourable prognosis. Close communication between clinician and pathologist is mandatory for making a correct diagnosis. Primary surgery with negative surgical margins seems to be the most successful treatment. However, management recommendations are not uniform since they are mostly based on case reports and small retrospective case series. Prospective and pooled multi-institutional studies are therefore needed.

A huge verrucous carcinoma of the lower lip reconstructed by double Abbe flap: A case report and literature review

Lip verrucous carcinoma is a rare low-grade neoplasm, with an unsightly appearance and locally aggressive nature. Treatment of verrucous carcinoma is as yet challenging, no well-defined guidelines for effective and safe management of this disease are available. A case of a patient with a huge verrucous carcinoma of the lower lip successfully treated by surgical excision and double Abbe flap reconstruction technique is presented, and striking features of lip locations of this tumor as well as their management are discussed.

Protocol for Treatment of Oral Verrucous Carcinoma - A Systematic Review and Meta-Analysis

Background

The objective of this study is to provide a structured protocol for the treatment of verrucous carcinoma (VC) based on size, bone invasion, recurrence and whether neck dissection is necessary or not. In addition, the study evaluates the probability of a wrong histopathological diagnosis.

Data Sources

A search was conducted in the Cochrane Library, PubMed and Google from January 1962 to October 2022 by using MeSH terms and keywords. Studies reporting treatment modalities for VC and different histopathological diagnoses after excision of the lesion were selected except case reports and review articles.

Study Eligibility Criteria

Thirteen articles were selected. Six hundred and thirty cases of VC were treated by surgery, surgery + neck dissection, radiotherapy, chemotherapy and combination therapy. Statistical analysis revealed surgical treatment as a preferred option. Despite being enlarged, the lymph node was negative for metastasis. So, in OVC cases neck dissection adds only unnecessary morbidity to patients.

Participants and Interventions

Radiotherapy or chemotherapy can be used to downstage the disease. 23.3% of cases reported wrong histopathology diagnosis.

Study Appraisal and Synthesis Methods

Patients treated for squamous cell carcinoma (SCC) will only experience unnecessary morbidity unless the correct diagnosis is made between VC and hybrid VC. Irrespective of size VC does not metastasise until there are no foci of SCC.

Conclusions

Surgical excision of T1- and T2-sized lesions can be performed under local anaesthetic as a biopsy procedure. T3 or T4 lesion can be resected with a safe margin. If it comes as hybrid VC or VC with close margin (0.5 cm, <0.5 cm), neck dissection and further margin should be excised as a second procedure respectively.

Malignant transformation of oral potentially malignant disorders in Taiwanese indigenous peoples: A nationwide retrospective cohort study

Malignant transformation of oral potentially malignant disorders (OPMDs) is a potential cause of oral cancer. Currently, there is no research investigating the rate of malignant transformation of OPMDs into oral cancer in indigenous Taiwanese peoples. This study aimed to retrospectively investigate whether ethnicity (indigenous vs non-indigenous people) plays a role in increasing the malignant transformation rate of OPMDs into oral cancer. This study used data from the oral mucosal screening database and the Cancer Registry File, both of which originated from the National Health Insurance Research Database. We matched the baseline characteristics to control for confounding factors between indigenous peoples and non-indigenous peoples (17,768 indigenous subjects vs 71,072 non-indigenous subjects; 1:4 match) and compared the 2 cohorts. After matching for confounding factors such as age, sex, habits, and OPMD subtype, the malignant transformation rate was not statistically higher for indigenous people than for non-indigenous people. We also discovered that indigenous people with oral verrucous hyperplasia might have a higher chance of malignant transformation into oral cancer than the non-indigenous cohort. We conclude that ethnicity is not a risk factor for the malignant transformation of OPMDs into oral cancer; however, indigenous people with oral verrucous hyperplasia need to pay special attention and are suggested to undergo regular follow-ups for the occurrence of oral cancer.

Oral Squamous Cell Carcinoma Frequency in Young Patients from Referral Centers Around the World

Oral squamous cell carcinoma (OSCC) commonly affects older patients; however, several studies have documented an increase in its incidence among younger patients. Therefore, it is important to investigate if this trend is also found in different geographic regions. The pathology files of diagnostic and therapeutic institutions from different parts of the globe were searched for OSCC cases diagnosed from 1998 to 2018. Data regarding the sex, age, and tumor location of all cases, as well as the histologic grade and history of exposure to risk habits of cases diagnosed as OSCC in young patients (≤ 40 years of age) were obtained. The Chi-square test was used to determine any increasing trend. A total of 10,727 OSCC cases were identified, of which 626 cases affected young patients (5.8%). Manipal institution (India) showed the highest number of young patients (13.2%). Males were the most affected in both age groups, with the tongue and floor of the mouth being the most affected subsites. OSCC in young individuals were usually graded as well or moderately differentiated. Only 0.9% of the cases occurred in young patients without a reported risk habit. There was no increasing trend in the institutions and the period investigated (p > 0.05), but a decreasing trend was observed in Hong Kong and the sample as a whole (p < 0.001). In conclusion there was no increase of OSCC in young patients in the institutions investigated and young white females not exposed to any known risk factor represented a rare group of patients affected by OSCC.

A new scoring system facilitating diagnosis of oral squamous malignancy on biopsy specimens

BACKGROUND

Morphological evaluation of oral mucosal biopsy is sometimes inconclusive, which may delay the diagnosis and treatment of oral squamous malignancy. Immunohistochemical biomarkers denoting oral squamous malignancy would be clinically helpful in such scenario.

METHODS

We first studied the expression patterns of four potential biomarkers (cytokeratin 13, cytokeratin 17, Ki-67 and laminin 5 gamma 2 chain) in an exploratory cohort containing 54 surgical specimens from confirmed oral squamous malignancies. A pattern score was assigned to each specific expression pattern of these four biomarkers. A total score from each specimen was then calculated by summing up the four pattern scores. A cut-off value of total score denoting oral squamous malignancy was then determined. Another 34 oral squamous malignancies that were misdiagnosed as non-malignant lesions on their pre-treatment biopsies were used as a validation cohort to test the clinical utility of this scoring system.

RESULTS

In the exploratory cohort, fifty-two (96%) of the 54 confirmed oral squamous malignancies had a total score of 9 and above. In the validation cohort, thirty-one (91%) of the 34 pre-treatment oral biopsy specimens also had a total score of 9 or above, supporting the feasibility of using this scoring system to predict immediate risk of oral squamous malignancy.

CONCLUSIONS

Our four-biomarker "oral squamous malignancy scoring system" provides reliable prediction for immediate risk of oral squamous malignancy on pre-treatment oral biopsies.

Malignant development of proliferative verrucous/multifocal leukoplakia: A critical systematic review, meta-analysis and proposal of diagnostic criteria

BACKGROUND

Proliferative verrucous/multifocal leukoplakia (PVML) is an oral potentially malignant disorder (OPMD) that exhibits high rates of malignant development (MD). This study aimed to analyse the risk of MD of PVML, as well as to investigate the possible risk factors associated with its malignization.

METHODS

A bibliographical search of the PubMed, Embase, Web of Science, and Scopus databases was conducted. PVML MD rates were calculated as a pooled proportion, and the risk factors were calculated as risk ratios, using fixed and random models based on the presence of heterogeneity.

RESULTS

From a total of 417 records, 16 articles were retrieved for inclusion. The subgroup analysis revealed a higher MD rate in the studies that were conducted in America, and, likewise, said studies involved a longer follow-up time (>6 years). There was a non-significant lower risk of malignization among males. A negative correlation was observed between MD and the year in which the studies were published.

CONCLUSIONS

The pooled MD of PVML was 65.8% (95% CI: 55.3-76.2, p < 0.001). Prospective studies of PVML must be designed using simple and universal clinical diagnostic criteria to be able to make an early diagnosis of this important OPMD and acknowledge the frequency of MD.

Cancer-Associated Stromal Cells Promote the Contribution of MMP2-Positive Bone Marrow-Derived Cells to Oral Squamous Cell Carcinoma Invasion

Simple Summary

Based on its invasiveness, oral squamous cell carcinoma (OSCC) shows two different subtypes: less-invasive verrucous squamous carcinoma (VSCC) or highly invasive squamous cell carcinoma (SCC). The stromal component influences OSCC progression and invasion. On the other hand, bone marrow-derived cells (BMDCs) are recruited into tumors and involved in tumor development. We hypothesized that stromal factors might also affect the relation of BMDCs and tumor invasion. We established the OSCC models transplanted with stromal cells from VSCC and SCC, and we compared the potential stromal factors of VSCC and SCC for the involvement of BMDCs in tumor invasion. Our study showed that stromal factors IL6 and IL1B might promote the contribution of MMP-2 positive BMDCs to OSCC invasion.

Abstract

Tumor stromal components contribute to tumor development and invasion. However, the role of stromal cells in the contribution of bone marrow-derived cells (BMDCs) in oral squamous cell carcinoma (OSCC) invasion is unclear. In the present study, we created two different invasive OSCC patient-derived stroma xenografts (PDSXs) and analyzed and compared the effects of stromal cells on the relation of BMDCs and tumor invasion. We isolated stromal cells from two OSCC patients: less invasive verrucous OSCC (VSCC) and highly invasive conventional OSCC (SCC) and co-xenografted with the OSCC cell line (HSC-2) on green fluorescent protein (GFP)-positive bone marrow (BM) cells transplanted mice. We traced the GFP-positive BM cells by immunohistochemistry (IHC) and detected matrix metalloproteinase 2 (MMP2) expression on BM cells by double fluorescent IHC. The results indicated that the SCC-PDSX promotes MMP2-positive BMDCs recruitment to the invasive front line of the tumor. Furthermore, microarray analysis revealed that the expressions of interleukin 6; IL-6 mRNA and interleukin 1 beta; IL1B mRNA were higher in SCC stromal cells than in VSCC stromal cells. Thus, our study first reports that IL-6 and IL1B might be the potential stromal factors promoting the contribution of MMP2-positive BMDCs to OSCC invasion.

Association of HPV and EBV in Oral Verrucous Squamous Cell Carcinoma and Oral Verrucous Hyperplasia

Objective  Oral verrucous squamous cell carcinoma or oral verrucous carcinoma (OVC) is a rare verrucous variant of oral squamous cell carcinoma (OSCC), which accounts for 2 to 12% of all oral carcinomas. Oral verrucous hyperplasia (OVH) is clinically similar to OVC and has been proposed to be a precursor lesion of OVC. Etiopathogenesis of both lesions is still inconspicuous. Oncogenic viruses such as human papillomavirus (HPV) and Epstein–Barr virus (EBV) have been reported to be associated with some cases of OSCC, and we hypothesized that it may act as a causative agent of these verrucous lesions. This study aimed to investigate frequency of HPV and EBV infections in OVC and OVH.

Material and Methods  Using polymerase chain reaction (PCR), a total of 35 formalin-fixed paraffin-embedded (FFPE) tissue samples, including 27 OVC samples and 8 OVH samples, were investigated for HPV and EBV infection. HeLa and B95-8 cell lines were used as positive controls of HPV and EBV PCR, respectively.

Results  All OVC and OVH samples show a positivity to GAPDH , whereas neither HPV nor EBV PCR products was detected in both OVC and OVH samples.

Conclusions  In summary, our study demonstrated that HPV and EBV are not involved in pathogenesis of OVC and OVH. Other etiologic factors contributing to OVC and OVH need to be further clarified.

Verrucous Carcinoma of Buccal Mucosa in Female: A Rare Case Report of Traumatic Tooth Origin

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.

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.

Verrucous carcinoma arising from a previous cystic lesion: a case report

Background

Verrucous carcinoma (VC) accounts for 1–10% of cases of squamous cell carcinoma (SCC) in the oral cavity, and 75% of VC occur in the oral cavity. Only 3% of primary intraosseous squamous cell carcinomas (PIOSCC), which means SCC occurring primarily in the bone, are VC. Verrucous carcinoma arising from odontogenic cysts (OC) is very rare, with only seven cases reported to date.

Case presentation

This study reported a case of a patient who underwent partial maxillectomy and neck dissection for VC that occurred in the right anterior maxilla. The patient was admitted to the emergency department at our institution 8 years ago and showed cystic lesions in the anterior maxilla on facial computed tomography (CT) images. Treatment through other departments including assessment of laceration in the mental region and only suture was performed. This report highlights a very rare case of VC in the right anterior maxilla arising from a previous cystic lesion.

Conclusions

Since PIOSCC can arise from OC, appropriate treatment of intraosseous cysts and regular radiologic evaluation are necesssary. Surgical exicision of the primary lesion without neck dissection can lead to good prognosis for patients with primary intraosseous verrucous carcinoma.

Mitogen-activated protein kinase signaling pathway in oral cancer

The mitogen-activated protein kinase (MAPK) signaling pathway is associated with tumor cell proliferation, differentiation, apoptosis, angiogenesis, invasion and metastasis. The present review assesses the involvement of the MAPK signaling pathway in oral cancer progression and invasion based on analysis of individual sub-pathways and their mechanisms of action. The regulation of this pathway for targeted oral cancer therapy is explored and the challenges confronting this, as well as corresponding potential solutions, are discussed. Exploring this pathway with an emphasis on its components, subfamilies, sub-pathways, interactions with other pathways and clinical practice modes may improve oral cancer treatment.