Présentation Clinique

Homme de 85 ans, tumeur buccale végétante du maxillaire supérieur. Resection chirurgicale.

Microscopie

Microscopy

La coupe transversale de la tumeur objective l'aspect végétant.

The whole mount of the tumor discloses its fungating pattern.

HE x 100. Portion superficielle, aspect papillomateux.

Low power, superficial area, papillomatous pattern.

HE x 200. Zone papillomateuse, coalescence.

Papillomatous pattern, coalescence.

HE x 400. Portion superficielle, maturation épidermoide, peu d'atypie.

Superficial area, slight atypia, and squamous maturation.

HE x 100. Portion profonde de la lésion.

Deep area of the lesion.

HE x 200. Infiltration du tissu conjonctif.

Invasion of the connective tissue.

HE x 400

Diagnostic Proposé:

Diagnosis Proposed:

Verrucous carcinoma (Ackerman's Surgical Pathology, 8th Ed.)

Verrucous carcinoma (Ackerman's tumor) is a variant of well-differentiated squamous cell carcinoma endowed with enough clinical, pathologic, and behavioral peculiarities to justify its being regarded as a specific tumor entity. The oral cavity is its classic location, but this lesion also has been reported in the larynx, nasal cavity, esophagus, penis, anorectal region, vulva, vagina, uterine cervix, and skin (particularly in the sole of the foot). Within the oral cavity, the most common sites are the buccal mucosa and lower gingiva. Most patients are elderly males, and there is a close connection with the use of tobacco, especially chewing or snuff dipping. Grossly, it presents as a large, fungating, soft papillary growth that tends to become infected and slowly invades contiguous structures. It may grow through the soft tissues of the cheek, penetrate into the mandible or maxilla, and invade perineurial spaces. Regional lymph node metastases are exceedingly rare, and distant metastases have not been reported.

The microscopic diagnosis of verrucous carcinoma may be difficult because of its well-differentiated character. A superficial biopsy will show only hyperkeratosis, acanthosis, and benign-appearing papillomatosis. Sections of an adequate biopsy show swollen and voluminous rete pegs that extend into the deeper tissues, where their pattern becomes quite complex. The most important differential feature with squamous cell carcinoma is the good cytologic differentiation throughout the tumor. Dr. Lauren Ackerman, who first described the entity, expressed this fact by stating: "If a lesion looks cytologically like carcinoma, it is not verrucous carcinoma." Image analysis studies have confirmed the size differences among the cells of these two tumors. Interestingly, in about one fifth of the cases, cytologically identifiable foci of squamous cell carcinoma occur within a lesion that looks otherwise like a verrucous carcinoma, hence the importance of thorough sampling. These hybrid tumors are said to be associated with a higher recurrence rate than pure verrucous carcinoma.

Resection is the treatment of choice. If surgery is inadequate, the tumor will recur. Radiation therapy is usually not used, since it may alter the nature of the tumor to a highly malignant, rapidly metastasizing, poorly differentiated squamous cell carcinoma. This has occurred in as many as 30% of the cases in some series, the average postirradiation interval being 6 months.

It is likely that most of the cases reported in the past as oral florid papillomatosis represent early and noninvasive stages of verrucous carcinoma. Along the same lines, the similar if not identical conditions known as verrucous hyperplasia, proliferative verrucous leukoplakia, verrucous keratosis, and leukoplakia verrucosa can be regarded as precursor lesions of verrucous carcinoma, from which they are distinguished by the fact that the verrucous process is superficial to the adjacent squamous epithelium.