Radiotherapy and verrucous carcinoma of the oral cavity. A study of 107 cases

Controversies in verruco papillary lesions of the oral cavity-A systematic review

INTRODUCTION

Verruco papillary lesions (VPL) in the oral cavity encompass a spectrum of lesions starting from benign, potentially malignant to entirely malignant tumors. Much of the controversies in these entities occur due to lack of consensus on the disease characteristics and the management. This systematic review was conducted to identify and describe different lesions categorized as VPL in the oral cavity and their association with malignancy.

METHODS

An electronic literature search was conducted in MEDLINE (via PubMed), Scopus, LILAC, IMSEAR, and CENTRAL databases, which retrieved a total of 1020 abstracts. These abstracts were managed through Rayyan and Mendeley software, and only 28 studies with high quality were included in the systematic review.

RESULTS

Studies were published from 1992 to 2021. From the extracted data, nine different entities under the umbrella term VPL were identified associated with malignancy. We describe the clinical and histopathological characteristics of these and propose a uniform framework for nomenclature.

CONCLUSIONS

Lack of well-planned research with adequate follow-up duration and inadequate quality standards are major barriers for the lack of evidence. The use of uniform nomenclature, as proposed in this study, and research at the molecular level will greatly reduce the controversies in understanding oral VPL associated with malignancy.

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.

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.

Treatment Pattern and Outcomes in Verrucous Carcinoma of Oral Cavity: A Single Institutional Retrospective Analysis from a Tertiary Cancer Center and Review of Literature

Verrucous carcinoma (VC) is a locally invasive uncommon histopathological variant of oral squamous cell cancer. There is paucity of literature regarding control rates in these cases. We intend to report the outcomes in terms of administered treatment and control rates. 28 patients of oral cavity verrucous carcinomas treated at our institute from March 2014 to December 2018 were reviewed retrospectively. Demographic profile, histopathological features and clinical outcomes were analyzed. Statistical analysis was performed with SPSS for Mac (version 23.0). Median age was 54 years (range 31-75) with M:F ratio of 25:3. Buccal mucosa was the most common site. All patients underwent surgical resection except one. Of these, 24 had neck dissection; 12 had supra-omohyoid neck dissection, eleven had modified neck dissection and one patient underwent radical neck dissection. Three patients had their histology upgraded to squamous cell carcinomas in the post-operative histopathology. The post-operative staging was as follows: 21% stage I and 35% stage II. One patient opted for non-surgical approach and received radical concurrent chemoradiotherapy. Median follow up was 12 months (range 6-36). Two patients had local failures and one had a regional failure. No distant metastasis was found. There was one death. 14-Months survival rate was 92%. Estimated 18 month loco-regional control rate was 92%. Curative surgical resection remains the cornerstone for VC of oral cavity. Any change of histopathology post-operatively to squamous cell carcinoma is a poor prognostic sign and needs appropriate adjuvant treatment.

Adjuvant radiotherapy is not supported in patients with verrucous carcinoma of the oral cavity

OBJECTIVE

To analyze the impact of adjuvant radiation therapy (RT) on overall survival (OS) and disease-specific survival (DSS) in patients with verrucous carcinoma (VC) as compared to squamous cell carcinoma (SCC) of the oral cavity.

STUDY DESIGN

Cross-sectional population analysis.

METHODS

Cases of nonmetastatic VC/SCC of the oral cavity were extracted from the Surveillance, Epidemiology, and End Results (SEER) database (1988-2013). Kaplan-Meier survivals, stratified according to T stage, were compared between VC and SCC for treatment with or without adjuvant RT.

RESULTS

A total of 18,819 VC/SCC cases were identified. There were 581 (3.1%) VC (mean age 69.6 years, 48.9% female) versus 18,238 (97.0%) SCC (mean age, 65.3, 37.1% female) patients. Verrucous carcinoma patients receiving surgery alone (N = 539) demonstrated a trend toward improved OS versus VC patients receiving surgery and RT (N = 40) (117.0 vs. 71.4 months, respectively, P = 0.119). There was a statistically significant improvement in DSS in VC patients receiving surgery alone (217.2 vs. 110.9 months, P = 0.05). Verrucous carcinoma patients treated with adjuvant RT demonstrated a trend toward a worse OS (71.4 vs. 93.0 months, P = 0.992) and DSS (110.9 vs. 162.3 months, P = 0.275) compared to SCC treated with adjuvant RT, suggesting a different biology and radiosensitivity between VC and SCC.

CONCLUSION

Verrucous carcinoma treated with adjuvant RT had a worse OS and DSS compared to both VC treated with surgery alone and SCC treated with surgery and adjuvant RT. Consideration should be given to surgical re-section rather than adjuvant RT in patients with positive margins or local recurrence.

LEVEL OF EVIDENCE

2C. Laryngoscope, 127:1334-1338, 2017.

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 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.

Locally advanced verrucous carcinoma of the oral cavity: treatment using customized mold HDR brachytherapy instead of hemi-maxillectomy

BACKGROUND

Oral verrucous carcinomas are locally invasive but rarely metastasize. Current treatment options include surgery and external beam radiotherapy (EBRT). In medical inoperable patients or irresectable tumors, high-dose-rate (HDR) brachytherapy is a valid alternative.

CASE

We present an 85-year-old man with functionally irresectable cT3N0M0 verrucous carcinoma superficially spreading along the upper alveolar ridge to the retro-alveolar triangle, with infiltration of the left soft and hard palate and buccal mucosa. Using a customized intraoral mold, this patient was treated with HDR brachytherapy delivering a dose of 48 Gy in 12 fractions three times per week. Treatment was well tolerated, and after prolonged confluent mucositis the tumor is in complete remission.

REVIEW OF LITERATURE AND CONCLUSION

The scarce literature on customized mold HDR brachytherapy in maxillary tumors is reviewed and recommendations for other head and neck tumors are given.

Verrucous carcinoma of the oral cavity: a clinico-pathologic appraisal of 133 cases in Indians

INTRODUCTION

Verrucous carcinoma (VC), a rare variant of squamous cell carcinoma is an established entity with distinctive morphology and specific clinical behavior. To date, only a small series of head and neck verrucous carcinomas have been reported in the literature.

MATERIALS AND METHODS

The present study evaluated 133 cases of verrucous carcinoma for the age, sex, site of involvement, duration of disease at the time of diagnosis, associated habits and common presenting symptoms, presence of other mucosal lesions, recurrence, and the histopathology.

RESULTS AND DISCUSSION

Verrucous carcinoma accounted for 16.08% among oral squamous cell carcinoma compared to 2-12% reported in the literature. VC was more common in males with greater predilection to buccal mucosa due to widespread use of tobacco chewing in Indian scenario. Age distribution was lower as compared to other studies with prominence in the fifth decade. Mandibular involvement was more frequent as compared to those in literature.

CONCLUSION

Development of recurrence following radiotherapy in few cases supports anaplastic changes by radiotherapy.

Radiochemotherapy with Vinblastine, Methotrexate, and Bleomycin in the treatment of verrucous carcinoma of the head and neck

OBJECTIVE

To explore whether the combined radiochemotherapy with Vinblastine, Methotrexate, and Bleomycin could be an effective alternative treatment to surgery in verrucous carcinoma (VC) of the head and neck.

METHODS

Combined radiochemotherapy was used in 12 patients with previously untreated VC. They were irradiated to equivalent tumor dose of 44-70 Gy (median, 56 Gy) and had > or = 2 courses of concomitant chemotherapy. Chemotherapy regimen consisted of prolonged intravenous infusions of Vinblastine 2 mg (day 1); Methotrexate 50 mg (day 2); Bleomycin 15 mg (days 2 and 3), and repetition at 2-3 week intervals.

RESULTS

Eleven of 12 patients were cured of VC, and one died of purulent meningitis associated with intracranial extension of VC from the oral cavity. Of 11 patients cured of VC, eight had advanced tumors. The median follow-up of cured patients was 3.6 years (range, 1.4-13.6 years). All the patients developed mucositis of grade > or = 3, whereas no serious late side-effects were recorded.

CONCLUSIONS

Combined radiochemotherapy with Vinblastine, Methotrexate, and Bleomycine is highly effective in the treatment of VC of the head and neck. It could be successfully used in the patients with inoperable VC or as an alternative to surgery.

Treatment results of oral verrucous carcinoma and its biological behavior

The biologic behavior of and optimal treatment for oral verrucous carcinoma (VC) remain controversial. We analyzed the clinicopathological characteristics of 12 patients with oral VC. Immunohistochemical techniques were used to evaluate p53 protein, CD44 variant 9, and proliferating cell nucleus antigen. The TNM classification (UICC, 1997) was T1 in 1 patient, T2 in 3, T3 in 4, and T4 in 4. All patients were classified as N0M0. Four patients were treated by surgery alone and 8 by surgery after chemotherapy, radiotherapy, or both. After surgery, two patients had primary recurrence of disease. Immunohistochemically, the proliferative activity of tumor cells as evaluated by proliferating cell nuclear antigen labeling index and p53 protein expression was similar in VC and well-differentiated squamous cell carcinoma. However, CD44 varient 9 expression was positive in 8 of 10 VC, suggesting that oral VC is associated with a low risk of lymph node metastasis. Positive CD44 variant 9 expression by most oral VCs, indicating a low risk of cervical lymph node metastasis, suggests that most cases can be controlled by surgical intervention.

Treatment of verrucous carcinoma of vulva with acitretin

We describe a 60-year-old patient with verrucous carcinoma of the vulva, which recurred 6 years after simple vulvectomy and radiotherapy. Treatment with acitretin led to significant improvement and ongoing disease control has been achieved with low-dose maintenance therapy of 10 mg acitretin daily.

Verrucous carcinoma, then and now

The salient clinical and pathological features of verrucous carcinoma, as first described by Ackerman in 1948, are reviewed. Two case reports are presented. The first concerns a personal experience with a patient who had five surgical procedures for multifocal oral verrucous carcinoma and remains alive and well 28 years after her initial treatment. The second report highlights the remarkable story of President Grover Cleveland's secret surgery for verrucous carcinoma of the palate in 1893. Current concepts about the management of this uncommon tumor are reviewed, as well as some recent investigations that deal with its etiology.

Verrucous squamous carcinoma of the nasal septum

We document only the second reported case of verrucous squamous carcinoma of the nasal septum. In both cases previous surgical treatment for assumed squamous papillomata had resulted in multiple recurrences necessitating formal surgical resection. Our patient has remained tumour-free during long-term follow-up.

Is primary radiotherapy an appropriate option for the treatment of verrucous carcinoma of the head and neck?

The literature on verrucous carcinoma of the head and neck was reviewed to analyse the use of primary radiation therapy in the treatment of this lesion. The results emphasize an overall local control rate of 43.2 per cent, and 6.7 per cent of true anaplastic transformation following irradiation. Diagnosis remains the fundamental problem: without a correct diagnosis of verrucous carcinoma, no correct treatment can be applied.

[Expression of proliferation markers PCNA and MIB 1 in verrucous squamous epithelial carcinoma of the oral cavity]

Expression of proliferation markers PCNA and MIB 1 was evaluated in 17 verrucous carcinomas and in five cases of normal squamous epithelium of the oral cavity. Immunohistochemistry revealed no significant differences in the proliferative activities. Highest expression was seen in the basal zones. Proliferative activity in more than 26% of cells is no longer compatible with verrucous carcinoma, but favours the diagnosis of squamous cell carcinoma.

Verrucous carcinoma of the skin and mucosa

The concept of verrucous carcinoma as a clinicopathologic variant of squamous cell carcinoma is worthy of recognition. It is known by a confusing array of names, such as Ackerman's tumor, Buschke-Loewenstein tumor, florid oral papillomatosis, epithelioma cuniculatum, carcinoma cuniculatum, and cutis papillomatosis carcinoides of Gottron. Its apparent clinical benignity may lead to lengthy periods of misdiagnosis, during which it is likely not to spread to distant lymph nodes, but rather to destroy a nose, mandible, or penis as it slowly but relentlessly extends into underlying tissue. Morphologically warty or verrucous, its relatively bland histologic features are often more suggestive of a verruca vulgaris or pseudoepitheliomatous hyperplasia than of squamous cell carcinoma to those unfamiliar with the diagnosis. Alternatively, when it extends into underlying tissues, it may be mistaken histologically for a benign adnexal tumor or even an epidermoid cyst. Therapy may also be challenging because recurrences are common and concerns about potential anaplastic transformation after radiotherapy are often expressed.