|Year : 2012 | Volume
| Issue : 1 | Page : 11-13
Management of oral verrucous carcinoma with CO 2 Lasers
Daya K Jangam, Umesh N Phad, Akshay S Raut
Department of Oral Medicine and Radiology, M.A. Rangoonwala College of Dental Sciences & Research, Pune, Maharashtra, India
|Date of Web Publication||15-Sep-2012|
Daya K Jangam
Department of Oral Medicine and Radiology, M A Rangoonwala Dental College, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Ackerman's tumour or Verucous carcinoma is a unique clinico-pathological rare variant of squamous cell carcinoma. The term "Verrucous" is used because of its fine, finger like surface projections. Verrucous carcinoma constitutes 2 to 4.5% of all forms of squamous cell carcinoma, occuring mainly in oral cavity and larynx, buccal mucosa being most commonly involved. A case of verrucous carcinoma involving mucosa of retromolar region in an adult male aged 63 years is being reported who was managed using CO 2 lasers. Post-surgical excision was without any post-operative complications. Repithelialization was within weeks and no signs of recurrence after follow up period of about six months. Thus it is concluded that CO 2 lasers can be good tool for surgical management.
Keywords: CO 2 , oral carcinoma, verrucous carcinoma
|How to cite this article:|
Jangam DK, Phad UN, Raut AS. Management of oral verrucous carcinoma with CO 2 Lasers. J Dent Lasers 2012;6:11-3
| Introduction|| |
Oral verrucous carcinoma is a rare tumor first described by Ackerman in 1948. It is a rare variant of squamous cell carcinoma with specific clinical and histological features. It is most closely associated with tobacco in various forms especially smokeless tobacco. The tumor grows slowly and locally, invasive in nature and unlikely to metastasize. Surgery has been the first choice of treatment for these lesions, and radiotherapy is controversial. Recently CO 2 lasers have been used for treatment of oral mucosal lesions including verruccous carcinoma. We are presenting here with a case of verruccous carcinoma in retromolar region which has been successfully treated using CO 2 lasers.
| Case Report|| |
A male patient aged 63 years reported to our department of oral medicine and radiology M.A. Rangoonwala dental college, with a chief complaint of growth in the left retromolar region since one year, which has gradually increased to the present size [Figure 1]. On inspection the growth appeared to be cauliflower like with broad base, non-tender, of about 2x2 cm in size [Figure 2]. Patient gave a history of chewing tobacco for a period of more than 10 years. There was no relevant medical history. Cervical lymph nodes were not palpable. A provisional diagnosis of proliferative verruccous leukoplakia was given.
Exicisional biopsy was done with CO 2 laser, [Figure 3] and [Figure 4] and histopathology revealed verrucous carcinoma. Characteristic features revealed were hyperkeratotic and hyperplastic epithelium with evidence of keratin plugging and broad based reteridges [Figure 5]. Epithelium exhibited dysplastic features and a few epithelial pearls. The basement membrane was intact. All the features were suggestive of verrucous carcinoma.
|Figure 5: Histopathological picture showing features of verrucous carcinoma|
Click here to view
| Discussion|| |
Oral verrucous carcinoma is a rare tumor first described by Ackerman.  It is a special form of well-differentiated squamous cell carcinoma with specific clinical and histological features. Various names are used in the literature to describe this entity, including Ackerman's tumor, Buschke-Loewenstein tumour, florid oral papillomatosis, epithelioma cuniculatum, and carcinoma cuniculatum. 
The oral cavity is the most common site of occurrence. In addition, it is known to occur in the larynx, pyriform sinus, esophagus, nasal cavity and paranasal sinuses, external auditory meatus, lacrimal duct, skin, scrotum, penis, vulva, vagina, uterine cervix, perineum, and the leg. ,
Verrucous carcinoma accounted for 16.08% among oral squamous cell carcinoma compared to 2-12% as was reported earlier in the literature. Verrucous carcinoma was more common in males with greater predilection to buccal mucosa due to widespread use of tobacco chewing in Indian scenario. Oral verrucous carcinoma traditionally occurs more commonly in older males, above the sixth decade.
Tobacco chewing is a significant etiologic factor for the development of Oral Verrucous carcinoma. Lesions often develop at the site where the tobacco was placed habitually. 
The strong association of Oral verrucous carcinoma with smoking, alcohol, and HPV infections is well known. There are very few studies from India, which have evaluated the clinical and pathological prognostic factors relevant to local recurrence and disease free survival for oral verrucous carcinoma. ,,
Surgery is considered the primary mode of treatment for oral verrucous carcinoma irradiation alone or in combination with surgery is rarely performed.
Oral verrucous carcinoma has an excellent prognosis with surgical management. Recently lasers have been widely used in dentistry and have been considered as ideal treatment modality for exophytic growths as they provide bloodless field with minimal or no need of anesthesia. CO 2 laser is the workhorse of contemporary laser surgery and emits a coherent light beam in the mid-IR region at 10600nm which is a major spectroscopic absorption peak for water. These lasers have unique application for the excision of soft tissue lesions affecting the mucosa. They produce results not achievable by scalpel or electrocautery. An outline is rapidly made using repeated single pulses (175 mJ/pulse, 0.2 mm at 0.5 W) to circumscribe the desired target tissue. The excisional depth can be easily controlled as CO 2 radiation is rapidly absorbed and dissipated and has a depth of penetration of 0.02 mm. ,,,
This also offers an advantage of limiting the transplantation of malignant or infected cells wherein there is always a chance of recurrence in such cases. Other advantages of CO 2 lasers are minimal bleeding, sterile surgical field, need for suturing eliminated, postoperative complication and recurrence rate is low. Post-surgical healing after laser excision progressed in our case with no postoperative complications. Repithelialization took place within five weeks and the patient was followed up for about six months with no signs of recurrence [Figure 6]. However prolonged close follow up of the cases is recommended due to the concept of "field cancerization". The prognosis of verrucous carcinoma is better than the other kinds of life threatening malignant diseases.
| Conclusion|| |
Thus it can be concluded that CO 2 laser is a dependable and revolutionary modality for surgical management of oral verrucous carcinoma.
| References|| |
|1.||Ackerman LV. Verrucous carcinoma of oral cavity. Surgery 1948;23:670-8. |
|2.||Schwartz RA. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol 1995;32:1-21. |
|3.||Spiro RH. Verrucous carcinoma, then and now. Am J Surg 1998;176:393-7. |
|4.||Ferlito A, Recher G. Ackerman's tumor (verrucous carcinoma) of the larynx: Clinicopathologic study of 77 cases. Cancer 1980;46:1617-30. |
|5.||Oliveira DT, de Moraes RV, Fiamengui Filho JF, Fanton Neto J, Landman G, Kowalski LP. Oral verrucous carcinoma: A retrospective study in Sao Paulo Region, Brazil. Clin Oral Invest 2006;10:205-9. |
|6.||Rajendran R, Sugathan CK, Augustine J, Vasudevan DM, Vijayakumar T. Ackerman's tumour (verrucous carcinoma) of the oral cavity: A histopathologic study of 426 cases. Singapore Dent J 1989;14:48-53. |
|7.||Tornes K, Bang G, Stromme Koppang H, Pedersen KN. Oral verrucous carcinoma. Int J Oral Surg 1985;14:485-92. |
|8.||Jacobson S, Shear M. Verrucous carcinoma of the mouth. J Oral Pathol 1972;1:66-75. |
|9.||Sundstrom B, Mornstad H, Axell T. Oral carcinomas associated with snuff dipping. Some clinical and histological characteristics of 23 tumours in Swedish males. J Oral Pathol 1982;11:245-51. |
|10.||Mortiz A. Oral Laser Application. In: Beer F, Goharkhay K, Schoop U, Strassi M, Verheyen P, Walsh LJ, et al. Editors. Berlin: Quintessenz Verlags-Gmbh; 2006. |
|11.||Trost D, Zacheri A, Smith MF. Surgical laser properties and their tissue interaction neurological surgery of ear. (Year Book) St. Louis: Mosby; 1992. p. 131-62. |
|12.||Rhys Evans PH, Frame JW, Brandrick J. A review of carbon dioxide laser surgery in the oral cavity and pharynx. J Laryngol Otol 1986:100:69-77. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]