eMedicine Specialties > Dermatology > Diseases of the Oral Mucosa

Oral Florid Papillomatosis: Differential Diagnoses & Workup

Author: Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Coauthor(s): Channing R Barnett, MD, Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Jun 12, 2009

Differential Diagnoses

Acanthosis Nigricans
Viral Infections of the Mouth
Oral Fibromas and Fibromatoses
Warts, Nongenital
Oral Granular Cell Tumors
Oral Hemangiomas
Squamous Cell Carcinoma

Other Problems to Be Considered

Verrucous hyperplasia of the oral mucosa
Verruca vulgaris
Proliferative verrucous leukoplakia - A rare oral mucosa disorder that may progress to oral squamous cell carcinoma34

Workup

Laboratory Studies

  • Ultrastructural studies may be considered.
    • Findings suggest a well-differentiated squamous cell carcinoma35 and are similar to those of conventional squamous cell carcinomas.
    • The findings include prominent microvilli, decreased tonofilaments, and underdeveloped desmosomes.
  • With oral verrucous carcinoma (VC), tissue typing for HPV may be beneficial, assuming it proves clinically useful to divide verrucous carcinomas on the basis of HPV infection.36 In one series, HPV was identified with the polymerase chain reaction in 13 of 29 cases of laryngeal verrucous carcinoma.20

Imaging Studies

  • The latest radiographic techniques, such as magnetic resonance imaging, should be used to define the extent of the tumor and to determine whether underlying bone or other structures are involved.
  • Computed tomography can be used to demonstrate the exact location and the extent of the tumor for preoperative staging and surgical planning.

Histologic Findings

The typical microscopic section shows a well-differentiated typical squamous cell carcinoma with verrucous clinical morphology.1

Histologically, oral verrucous carcinoma shows exophytic and endophytic growth patterns.1 Its massively hyperplastic and exophytic epidermis has marked hyperkeratosis, sometimes with parakeratosis. Its prominent granular layer has tumor cells that may be vacuolated, resembling and indistinguishable from the koilocytes of condylomata acuminata.

Verrucous carcinoma is characterized by blunt projections of well-differentiated epithelium supported by an edematous stroma, with chronic inflammatory cells of lymphohistiocytic origin at its infiltrating margins. These blunt tumor masses extend into the dermis and deeper structures, forming sinuses and keratin-filled cysts. Bulbous islands of benign-appearing epithelium may infiltrate the subcutaneous tissue. This deceptively benign quality is associated with a basement membrane adjacent to its basal epithelial layer despite the composition of infiltrating tumor islands.21

Rare areas of focal disruption of the basement membrane are noted in oral verrucous carcinomas. Thus, neither the presence nor the absence of a basement membrane is a reliable indicator of tumor behavior. Atypical mitotic figures, individual cell necrosis, dyskeratosis, and multinucleated keratinocytes are rarely, if ever, evident. Centripetal keratinization of individual keratinocyte islands may be seen, but horn pearls are not. Individual cell cytologic features are relatively benign, with minimal dysplasia. Individual cells may be large and have big nuclei and prominent nucleoli. Occasionally, giant nuclei and enlarged malpighian keratinocytes may be evident. Intracytoplasmic glycogen is scant in verrucous carcinoma, as compared with keratoacanthoma and pseudoepitheliomatous hyperplasia.

Some oral mucosal verrucous carcinomas may be associated with small foci of floridly malignant squamous cell carcinomas,37,38,28 adjacent ordinary squamous cell carcinomas,39 or regional node metastases.39,40 In one study,37 21 (20%) of 104 oral verrucous carcinomas had similar foci with less differentiation than that of the verrucous carcinoma. Such foci of dysplasia are associated with a doubled recurrence rate and a 10% incidence of lymph node metastases.38 Therefore, careful sectioning to remove as much tumor as possible is indicated.

Radiation therapy has been implicated in the anaplastic transformation of some verrucous carcinomas,40 although anaplastic transformation may represent a possible terminal event in the natural progression of verrucous carcinoma.41 This phenomenon may be an example of a verrucous carcinoma undergoing programmed dedifferentiation to become a classic squamous cell carcinoma. The hybrid verrucous carcinoma–squamous cell carcinoma deserves careful scrutiny.

The extraoral expansion of a local tumor into the underlying cartilage and bone results in moderate dyskeratosis and numerous mitotic features as the bone is replaced by tumor. Acute and chronic inflammation and a granulation tissue reaction are also present. Tumor cells are usually not found in the blood vessels or the lymphatics; this finding is presumably correlated with the general absence of metastases in patients with mucosal verrucous carcinoma.

An ordinary squamous cell carcinoma may be a clinically silent verrucous carcinoma with histologic patterns reflecting its warty and exophytic surface. If clusters of poorly differentiated cells are present, the tumor is a conventional squamous cell carcinoma with a high malignant potential and a tendency to metastasize. However, typical verrucous carcinomas with foci of conventional squamous cell carcinoma, that is, the hybrid verrucous carcinoma–squamous cell carcinoma, may be troubling.

The distinction between verrucous carcinoma and a large and persistent verruca vulgaris may be difficult at both clinical examination and histologic examination. Verrucous carcinoma and verruca vulgaris both have the keratinocytic vacuolization that is said to be characteristic of viral warts.42 Avoid obtaining only a small superficial skin biopsy specimen; larger specimens facilitate the correct diagnosis. Verrucous hyperplasia of the oral mucosa must also be considered; it is best evaluated in biopsy specimens obtained from the lesional margins.43

More on Oral Florid Papillomatosis

Overview: Oral Florid Papillomatosis
Differential Diagnoses & Workup: Oral Florid Papillomatosis
Treatment & Medication: Oral Florid Papillomatosis
Follow-up: Oral Florid Papillomatosis
References
[ CLOSE WINDOW ]

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Further Reading

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Keywords

oral florid papillomatosis, verrucous carcinoma, Ackerman's tumor, Ackerman tumor, carcinoid mucous papillomatosis, oral cavity and aerodigestive tract verrucous carcinoma, oral florid verrucosis, giant mucocutaneous papillomatosis, nonmetastasizing papillomatosis, squamous cell carcinoma, multifocal papillomavirus epithelial hyperplasia

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Contributor Information and Disclosures

Author

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Channing R Barnett, MD, Staff Physician, Department of Dermatology, University of Medicine and Dentistry of New Jersey
Channing R Barnett, MD is a member of the following medical societies: Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Julie C Harper, MD, Assistant Program Director, Assistant Professor, Department of Dermatology, University of Alabama at Birmingham
Julie C Harper, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Stiefel Honoraria Speaking and teaching; Allergan Honoraria Speaking and teaching; Intendis Honoraria Speaking and teaching; Coria Honoraria Speaking and teaching; Sanofi-Aventis Honoraria Speaking and teaching

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Drore Eisen, MD, DDS, Consulting Staff, Department of Dermatology, Dermatology Research Associates of Cincinnati
Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, and American Dental Association
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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