Dr F Bhamjee

Oral medicine case– The diagnostic dilemma of Verrucous carcinoma

 Main complaint and medical history:

An 80 year old otherwise healthy male presented at the Oral Medicine Clinic at Groote Schuur Hospital complaining of a growth in his cheek. The growth is asymptomatic, however appears to be enlarging more so within the last 2 years. The patient is a past smoker and drinker, however stopped smoking and drinking approximately 20 years ago. He indicated that the lesion was completely removed 10 years ago and was informed that is was benign. The previous histology report could not be attained as this biopsy was not performed within South Africa. Since then the recurrence was noticed approximately a year after being excised.


Clinical findings:

The extra-oral examination revealed no lymphadenopathy or TMJ abnormalities. On the left cheek (close to the angle of the mouth) the skin appears atrophic, hypopigmented, with a fibrotic corrugated appearance – in comparison to the surrounding skin tissue.

Figure 1: Skin at left side of cheek

The intra-oral examination revealed a large, broad based, irregular shaped, exophytic papillary, asymptomatic lesion involving almost the entire left buccal mucosa. The lesion had a verrucous, corrugated, mixed red and white surface which did not slough or bleed upon examination.

Figure 2: Soft tissue mass involving almost the entire aspect of the left buccal mucosa.

Differential diagnosis:

Based on the clinical findings and history the following provisional diagnosis were considered:

  • Verrucous carcinoma
  • Proliferative verrucous leukoplakia
  • Squamous cell carcinoma
  • Verrucous leukoplakia


An incisional biopsy was performed under local anaesthetic from two sites of the lesion. The patient was provided post-operative instructions, analgesics and a 0,2 % chlorhexidene digluconate mouth rinse.

The biopsy specimen was examined by a general pathologist and the histopathological report stated that the lesion consisted of fragments of tissue demonstrating psuedoepitheliomatous hyperplasia. The surrounding vicinity demonstrates a mixed inflammation. Mild dysplasia is present and there is no evidence of malignancy.

Due to the nature of the lesion, patient’s history of smoking and concern that the lesion may be a malignancy, a second incisional biopsy (also consisting of two tissue specimens) was performed. The second biopsy specimens were examined by an oral pathologist who was also able to compare and review the initial specimens.The histopathological report revealed heavily keratinized irregular, slightly clefted surfaces with parakeratosis extending into clefts. Marked bulbous hyperplasia of the basal aspect of the epithelium associated with mild atypia and dense subepithelial chronic inflammatory infiltrate. Based on the clinical and histopathological findings a diagnosis of verrucous carcinoma was reached.

The patient was referred to Head and Neck Oncology for further management.

This case illustrates the importance of multiple biopsy sites when dealing with such a large lesion of this nature.