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Verrucous Carcinoma (Ackerman’s Tumour)of Mobile Tongue

Kuldeep Singh, Prmod Kalsotra*, Ruchi Khajuria, Monika Manhas**

CASE REPORT

From the Postgraduate Department of Pathology, *ENT, & **Physiology Govt. Medical College, Jammu (J&K).Correspondece to: Dr. Kuldeep Singh, C-4 Medical Enclave Jammu-180016

IntroductionVerrucous carcinoma is an uncommon but distict

variety of well differentiated squamous cell carcinomafirst delineated as a clinico-pathologic enttity byAckerman in 1948 (1). Predominantly being a squamousmucosal lession, verrucous carcinoma may also be foundon cutaneous surfaces. Whether the carcinoma occur inthe upper aerodigestive tract (verrucous carcinoma), onthe genitalia (condyloma acuminatum), or on extremities(carcinoma cuniculatum), they are essentially the sameneoplasm with slowgrowing, locally invasive and non-metastasizing behaviour (2) . The mucosal membrane ofhead and neck are sites of prediction, with the oral cavityand larynx especially at the risk (2).

The macroscopic appearance of Ackerman’s trumourdepends on several factors like duration of lesion, degreeof keratinization and the changes in adjacent mucosa.The fully developed carcinoma in an exophytic gray tored bulky lesion with a rough, shaggy, papillomatoussurface. The term “Verrucous” is used because of itsfine, finger like surface projections (3). It may growthrough soft tissue of cheeks, penetrate into mandible or

AbstractAckerman’s tumour or Verucous carcinoma is a unique clinico-pathological variant of squamous cellcarcinoma, occuring mainly in oral cavity and larynx, buccal mucosa being most commonly involved.Onecase of verrucous involving tip of tongue (T1N0M0/Stage 1) in an adult male is being reported whounderwent wide field surgical excision. The clinico-pathological featuire of verruccous carcinomaare being discussed.Key WordsCarcinoma, Verrucous

maxilla and invade perineural space (4). Regional lymphnode metastasis is rare and distant metastasis has notbeen reported. The cell kinetics of verrucous carcinomaare distictive, containing a thick zone of non-proliferating,non keratinizing cells between the basal germinative layerof normal squamous mucosa, lacking the S-phase cells(5) Incontrast,non-verrucous sqamous cell carcinomamanifests S-phase cells distribution throughout nonkerantinized zones. It is likely that most of cases reportedin the past as oral florid papillomatosis represnt earlyand non-invasive stage of verrucous carcinoma (6).Case Report

A 70 year old male patient presented with an expohyticgrowth on tip of tongue with a rough, shaggy andpapillomatous surfaces, for a period of 6 months. Thegrowth was 2 cm x 1.0 cm in its greatest dimensionswith no history of trauma, oral bleeding, dysphagia orany speech problem. On palpation, the growth wasgreyish white, non-friable, non-tender, with well definedraised margins and no infiltrative induration. Cervicallumph nodes were not palpable. The patient underwent

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DiscussionVerrucous carcinoma most of the times goes

unrecognised or unchallenged due to benign indolenttumour behavior. Clinical leucoplakia often characterisesthe mucosa from which the neoplasm originates.Verrucous carcinoma appears to be a part of histologiccontinuum of leucoplakia with verrucous hyperplasia asa part of such spectrum (2) while others considerverrucous hyperplasia as a distict clinico-patholigicalentity (7) with its characterstics (Table 1). In the oralcavity, veruccous carcinoma constitutes 2 to 4.5 % of allforms of squamous cell carcimonas (8) seen mainly inmales above 50 years of age and having a closeconnection with use of tobacco especially chewing ofsnuff dipping. This is also associated with high incidence(37.7%) of second primary tumour sychronus ormertachronus, mainly in oral mucosa (10). Verrucouscarcinoma has excellent prognosis because of its slowgrowth and gravity with which it metastasize to regional

lymph nodes (3). Later in the course the contiguousstructure may be involved with time and adjacent tisssuesincluding bone and cartilage may be invaded anddestroyed. Microscopically, veruccous carcinoma areusually broad based and locally invasive with papilaryfronds consisting of highly differentiated squamous celllacking usual criteria of overt malignancy. Rarely mitosisis seen. Surface is usually covered by keratin layers.The invasive margin is invaribly a slow ‘pushing’ onealongwith inflammatory reaction in the stroma. Becauseof deceptive benign appearance of neoplastic cells, anaccurate pathological diagnosis requires a sufficientbiopsy specimen that contain infiltrative features ofverrucous carcinoma. A focus of conventional invasivesquamous cell carcinoma within the verrucous carcinomais seen in 20 percent of patients akin to the phenomenonof anaplastic transformation in lyrnx (2).

There is a considerable controversy in the literatureregrding ‘anaplastic transformation of verrucouscarcinoma following irradiation therapy in 10-20 percentcases (4,11,12,13). Following irradiationa small proportionof verrucous carcinoma are reported to have changedtheir biological behaviour from indlent low grade locallydestructive lesion to a highly malignant, metastasizingand fatal tumor, (4,11,12,13) with extremenly short latent

wide-excision taking safe oncological margin, under localanaesthesia and it was closed primarily using two layersof 2.0 vicryl sutures. The post-operative histopathologicalexamination revealed features of verrucous carcinoma(Fig-I) depicting swollen and voluminous rate pigsextending into deeper tissues lacking cytological atypia.Occasional mitotic figure was present.

1 Sites of prediction Oral Cavitry, larynx

2 Age/Sex Men over 50 years.

3 Habits Tobacco user, poor oral hygiene.

4 Grade of malignancy Low grade of local significance only.

5 Metastatic None in bonafide cases.

6 Gross appearance Exophytic of fungating usuallykeratinizing.

7 Associated mucosal Leukoplakia, metachronous orchanges synchronous squamous cell neoplasm

8 Differentiation of cells High grade, Uniform.

9 Cytologic feature of Rate to absentMalignancy

10 Depth of lesion Pushing of blunt invasion.

11 Cellular (host) response Usually predominant.

12 Hybrid malignancy` 20% of case approx.

Table 1. Clinico-pathological charracteristics of Verrucouscarcinoma

Fig 1. Histological feature of verrucous carcinoma, depicting swoolen erte pegs lacking cytological atypia. occasional mitotic figure is seen (10x)

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period of transformation. other authors don’t believe inthis ‘dedifferentiation’ phenomonon (2,10) and accountthis observation due to presence of ‘hybrid tumors’, i.epresence of foci of less differentiated squamous cellcarcinoma within verrucous carcinoma.

Because of reported incidence of anaplastictransformation following radiotherapy, many centresrecommend wide field surgical resection with good onco-clearance as preferred treatment modality While othersrecommend that verrucous carcinoma should be treatedas other squamous cell carcinomas with the treatmentmodality determined by effectiveness of control withoutregarding the potential risk of its developing into a farmore aggressive lesion after irradiation (2,14).References

1. Ackerman LV. Verrucous carcinoma of the oral cavity.Surgery 1948; 23: 670.

2. Bataakis JG, Hybels R, Crissman JD, Rice DH. Thepathology of head and neck tumors : verrucous carcinoma.Part 15. Head Neck Surg 1982; 5: 29.

3. Mehta FS, Hammer JE. Tobacco related, oral mucosal lesionand conditions in India. Publication : Basic dental researchunit. Tata Institute of fundamental reaserch. 1983; 3: 4.

4. Demian SD, Bushkin FL, Echevarria RA. Perineuralinvasion and anaplastic transformation of verrucouscarcinoma. Cancer 1973; 32: 395-401.

5. Prioleau. P G, Santa Cruz DJ, Meyer JS et al. Verrucouscarcinoma : A light and electron microscope auto radiographicand immunofluorescence study. Cancer 1980; 45: 2849.

6. Wechsler HL,Risher ER Oral florid papillomatosis.Clinical pathological and electron microscopicobservations. Arch Dermatol 1962; 86: 140-52.

7. Sheer M. Pindborg J.J verrucous hyperplasia of the oralmucosa. Cancer 1980; 46: 1855.

8. Jacobson S, Sheer M. Verrucous carcinoma of the monbth.J Oral Pathol 1972; 1: 66-75.

9. Sundstrom B, Mornstead H, Axell T. Oral Carcinomaassociated with snuff dippinmg. Some clinical andhistological characterstics of 23 tumors in Swedish male.J Oral Pathol 1982; 11: 245-51.

10. Medinal JE, Diechtel W, Luna MA,Verrucous squamouscarcinoma of the oral cavity. A Clinico pathological studyof 104 cases. Arch Otolaryngol 1984; 110: 437.

11. Fonta EA, Greenlaw RH, Rush BF. Verrucous squamouscell carcinoma of the oral cavity. Cancer 1969; 23: 152-62.

12. Kraus FT, Perez MC. Verrucous carcinoma : Clinical andpathologic study of 105 cases involving oral cavity, larynxand genitalia. Cancer 1966; 19: 26.

13. Perez CA, Kraus FT, Evanes JC, et al. Anaplastictransformation in verrucous carcinoma of the oral cavityafter radiationb therapy. Radiol 1966; 86: 108.

14. Mcclure DL, Gullane PJ, Slinger RP, Wyscocki GP.Verrucous carcinoma - Changing concepts in managementJ Otolaryngol 1984; 13: 7.