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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 9  |  Issue : 2  |  Page : 118-121

Application of diode laser for the management of oral verrucous carcinoma mimicking Candidiasis


1 Department of Oral and Maxillofacial Surgery, School of Dental Sciences, KIMSDU, Karad, Satara, Maharashtra, India
2 Department of Oral Pathology, Microbiology and Forensic Odontology, School of Dental Sciences, KIMSDU, Karad, Satara, Maharashtra, India
3 Department of Periodontology, School of Dental Sciences, KIMSDU, Karad, Satara, Maharashtra, India

Date of Web Publication26-Nov-2015

Correspondence Address:
Kumar Nilesh
Department of Oral and Maxillofacial Surgery, School of Dental Sciences, Krishna Hospital, Karad, Satara, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-2868.170566

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  Abstract 


Oral verrucous carcinoma (OVC) is a variant of oral squamous cell carcinoma which shows a local invasive pattern without any distant metastases. Accurate diagnosis of OVC depends on a careful association between clinical and histological features of the lesion. This paper reports a case of OVC over mandibular alveolar mucosa, mimicking Candidiasis. Use of diode laser for the management of the lesion is also described.

Keywords: Alveolar mucosa, Candidiasis, diode laser, verrucous carcinoma


How to cite this article:
Nilesh K, Malik NA, Vibhute N, Suragimath G. Application of diode laser for the management of oral verrucous carcinoma mimicking Candidiasis. J Dent Lasers 2015;9:118-21

How to cite this URL:
Nilesh K, Malik NA, Vibhute N, Suragimath G. Application of diode laser for the management of oral verrucous carcinoma mimicking Candidiasis. J Dent Lasers [serial online] 2015 [cited 2021 Oct 23];9:118-21. Available from: https://www.jdentlasers.org/text.asp?2015/9/2/118/170566




  Introduction Top


Oral verrucous carcinoma (OVC) is a unique clinicopathological variant of squamous cell carcinoma, first described by Ackerman in 1948.[1] Unlike squamous cell carcinoma, OVC is slow-growing, locally invasive in nature and unlikely to metastasize.[2]

Clinically true OVC presents as a rough textured, exophytic, white to red papillary growth. However, OVC has the propensity to mimic other benign tumors of the oral cavity. An accurate pathological diagnosis of OVC is facilitated by an adequate tumor sample and close collaboration between the clinical and the histological features. Surgical excision remains the workhorse for the treatment of OVC. Recently, CO2 lasers have been used for the treatment of various oral mucosal lesions including OVC.[3]

We report here a patient who presented with a white keratotic plaque over the mandibular mucosa that had been previously misdiagnosed and unsuccessfully managed as oral Candidiasis. Diode laser was used for the successful management of the lesion.


  Case Report Top


A 35-year-old female reported with a complaint of nonhealing white patch in her oral cavity. The patient first noticed the patch 6 months prior, which had gradually grown to its present form. No pain or discomfort was reportedly associated with the lesion. The patient gave no history of oral tissue-abusive habits. Medical history was noncontributory. The patient had undergone an incisional biopsy at a private dental clinic 6 months back, whose diagnosis was of chronic Candidiasis. Repeated antifungal therapy was prescribed without remission of the lesion.

Intra-oral examination showed a verrucous white growth over edentulous right mandibular alveolar ridge extending from the distal aspect of the first premolar to mesial aspect of the second molar, measuring about 2 cm × 1.5 cm in size. The lesion appeared more hyperplastic and pale on the lingual surface [Figure 1]. On palpation, it was nontender, firm, and nonscrapable. Cervical lymph nodes were not palpable. An orthopantomogram was advised which showed no underlying bone involvement. A linear radiopacity was seen overlying the alveolar bone suggestive of the soft tissue shadow [Figure 2].
Figure 1: Clinical presentation of the lesion as white patch over mandibular alveolar gingiva

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Figure 2: Orthopantaomogram showing no bone involvement; however a shadow of the soft tissue lesion is appreciated over the alveolar crest

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The differential diagnosis included verrucous leukoplakia, verrucous carcinoma, and squamous cell carcinoma. Two incisional biopsies were performed in different areas of the lesion and submitted to histopathological analysis. Histological examination of the tissue specimen showed an exophytic growth with marked epithelial proliferation and downward growth in the form of broad, bulbous rete ridges pushing into the connective tissue. Parakeratin plugging was seen. Subepithelial connective tissue showed dense chronic infiltration. No break in continuity of the basement membrane was seen. The microscopic features were suggestive of verrucous carcinoma [Figure 3].
Figure 3: Photomicrograph of the lesion (H and E Stained;, ×4 magnification) showing exophytic tumor composed of proliferating sheets of stratified squamous epithelium (a); Perakeratin lining the clefts with perakeratin plugging is also appreciated which is hallmark of oral verrucous carcinoma (b)

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Excision of the lesion was planned under local anesthesia. A diode laser (Zolar™) 980 nm was used at 0.8–1.2 W to cut the mucoperiosteum with a 2–3 mm clinically safe margin around the lesion. Use of laser reduced the volume of local anesthetic solution required for regional anesthesia and provided a relatively bloodless field of operation. The lesion was then dissected over the alveolar bone with molt periosteal elevator. The buccal mucosa was undermined and advanced over the bare alveolar bone and sutured with the lingual soft tissue margin to attain primary closure. The excised specimen [Figure 4] was submitted for histopathological evaluation, which confirmed the diagnosis of verrucous carcinoma. The patient at 1-year follow-up showed normal healing, without any recurrence [Figure 5].
Figure 4: Excised specimen

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Figure 5: One-year postoperative picture

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  Discussion Top


Various types of verrucous carcinoma has been described in the literature depending on the site of occurrence; ano-urogenital (giant condyloma acuminatum and Buschke-Lowenstein tumor), oro-aerodigestive (Ackerman tumor and oral florid papillomatosis),[4] feet (carcinoma cuniculatum and epithelioma cuniculatum), and other cutaneous sites (cutaneous verrucous carcinoma and papillomatosis cutis carcinoides). OVC is a special form of well-differentiated squamous cell carcinoma with specific clinical and histological features, first described by Ackerman in 1948.

Verrucous carcinoma of the oral cavity is typically associated with tobacco use and/or human papillomavirus (HPV) positivity.[5] Our case was not tested for HPV, and the patient had no history of tobacco use or other identifiable risk factors.

OVC usually presents as nonulcerated white exophytic papillary growth over the mucosa, with distinct margins. Variations in this classic presentation may occur infrequently. However, verrucous hyperplasia and verrucous keratosis may appear similar in clinical presentation.[6] The definitive diagnosis of OVC requires identification of the microscopic criteria described by Ackerman along with concurrence of the clinical appearance and behavior of the lesion.[7] The histopathological diagnosis of verrucous carcinoma with a single or superficial tissue specimen can often be erroneous and inconclusive. In the present report, clinical presentation and inadequate histopathological analysis of the incision biopsy specimen probably lead to the misdiagnosis of the lesion initially as Candidiasis. A similar case of OVC of the maxillary alveolar mucosa misdiagnosed as Candidiasis has been previously reported in the literature.[8]

Surgical removal of the lesion with a safe margin of normal tissue is the treatment of choice for OVC with good prognosis in reported cases. Neck dissection is not indicated for any pure OVC, given the absence of nodal metastases; cervical adenopathy may be associated with OVC, representing reactive changes and not a metastatic disease.[9] In recent, the lasers have been widely used in dentistry and have been considered as an ideal treatment modality for exophytic growths as they provide the bloodless field with minimal or no need of anesthesia. Jangam et al. reported the use of CO2 lasers for excision of OVC involving retromolar area.[3] Soft tissue diode laser (980 nm) was used for excision of the lesion in our present case along with the advancement of the buccal mucosal flap over the alveolar bone for primary closure. Previous clinical applications of diode laser (980 nm) in oral surgical procedures have shown that it provides more precise incision margin as compared with other laser systems.[10] The cutting effect can be similar to the CO2 laser and the coagulation properties comparable to the neodymium-doped yttrium aluminum garnet laser.[11]


  Conclusion Top


Our case reports, the pitfall in diagnosis of OVC, due to inadequate clinical assessment and pathological under-diagnosis. The definitive diagnosis of OVC requires identification of the microscopic criteria described by Ackerman along with concurrence of the clinical appearance and behavior of the lesion. The histopathological diagnosis of verrucous carcinoma with a single or superficial tissue specimen can often be erroneous and inconclusive. This case reiterates need of adequate and multiple tissue specimens from representative areas for histological evaluation and correlation of clinical and microscopic features for the definitive diagnosis of the lesion. Diode laser for the management of OVC is also reported for the first time. Use of laser for excision the lesion reduces the volume of local anesthetic solution required for regional anesthesia and provides a relatively bloodless field of operation, thereby emphasizing its benefits over conventional surgical excision.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery 1948;23:670-8.  Back to cited text no. 1
[PUBMED]    
2.
Saito T, Nakajima T, Mogi K. Immunohistochemical analysis of cell cycle-associated proteins p16, pRb, p53, p27 and Ki-67 in oral cancer and precancer with special reference to verrucous carcinomas. J Oral Pathol Med 1999;28:226-32.  Back to cited text no. 2
    
3.
Jangam DK, Phad UN, Raut SA. Management of oral verrucous carcinoma with CO2 lasers. J Dent Lasers 2012;1:11-3.  Back to cited text no. 3
    
4.
Ferlito A, Recher G. Ackerman's tumor (verrucous carcinoma) of the larynx: A clinicopathologic study of 77 cases. Cancer 1980;46:1617-30.  Back to cited text no. 4
[PUBMED]    
5.
Eisenberg E, Rosenberg B, Krutchkoff DJ. Verrucous carcinoma: A possible viral pathogenesis. Oral Surg Oral Med Oral Pathol 1985;59:52-7.  Back to cited text no. 5
[PUBMED]    
6.
Alkan A, Bulut E, Gunhan O, Ozden B. Oral verrucous carcinoma: A study of 12 cases. Eur J Dent 2010;4:202-7.  Back to cited text no. 6
    
7.
Spiro RH. Verrucous carcinoma, then and now. Am J Surg 1998;176:393-7.  Back to cited text no. 7
    
8.
Garcia N, Oliveira DT, Hanemann AC, Pereira AC. Oral verrucous carcinoma mimicking a chronic Candidiasis: A case report. Oncol Med 2012;6:1-3.  Back to cited text no. 8
    
9.
Santoro A, Pannone G, Contaldo M, Sanguedolce F, Esposito V, Serpico R, et al. A troubling diagnosis of verrucous squamous cell carcinoma ("the Bad Kind" of Keratosis) and the Need of Clinical and Pathological correlations: A review of the literature with a case report. J Skin Cancer 2011;2011:370605.  Back to cited text no. 9
    
10.
Romanos G, Nentwig GH. Diode laser (980 nm) in oral and maxillofacial surgical procedures: Clinical observations based on clinical applications. J Clin Laser Med Surg 1999;17:193-7.  Back to cited text no. 10
    
11.
Rastegar S, Jacques SL, Motamedi M, Kim BM. Theoretical analysis of equivalency of high-power diode laser (810nm) and Nd:YAG laser (1064nm) for coagulation of tissue: Predictions for prostate coagulation. Laser Tissue Interact 1992;64:150-60.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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Abstract
Introduction
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Discussion
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