Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Verrucous Carcinoma of the Head and Neck Verrucous carcinoma is a rare variant of well differentiated squamous carcinoma that was first described by Lauren Ackerman in 1947. He noted that this lesion had a characteristic morphologic appearance and specific clinical behavior and should be separated from other epidermoid carcinomas because even with extensive lesions it had an excellent prognosis with proper treatment. This lesion has a predilection for mucous membranes of the head and neck and is most commonly found in the oral cavity followed by the larynx. In the oral cavity and larynx this lesion is primarily a disease of white males greater than 50 years of age. It makes up 2.45% of all squamous cell carcinomas in the oral cavity and 1 to 3.4% in the larynx. Chewing tobacco is the primary etiologic factor for oral cavity lesions. Cigarette smoking is highly correlated with laryngeal lesions but has not been identified as an etiology. Human papillomavirus 16 related DNA sequences have been isolated from verrucous carcinoma of the larynx by Brandsma et al in six out of six patients examined. At M.D. Anderson 40% of the oral cavity lesions have also had HPV 16 related sequences isolated. This suggests HPV may play a role in the development of this disease but additional research in this area needs to be done to clarify the issue. The diagnosis is made from the clinical findings of an exophytic, gray, bulky lesion with a papillomatous character and from the pathological findings of a broadly based tumor that is locally invasive. It is very important for the surgeon and pathologist to maintain close communication because the surgeon tends to overestimate the malignant potential of this lesion while the pathologist will often underestimate its neoplastic features. Microscopically this lesion is composed of highly differentiated squamous cells, is broadly based, and has large blunt ended rete ridges with an intact basement membrane. An inflammatory reaction is also often present in the stroma composed of lymphocytes and plasma cells. This disease has been primarily treated by surgery or radiotherapy for both oral cavity and laryngeal lesions. Overall the most effective treatment has been surgical excision although Schwade et al and Burns et al had equally good results with radiation in the treatment of laryngeal verrucous carcinoma. Anaplastic transformation of verrucous carcinoma following radiotherapy has been a topic of considerable controversy. McDonald et al critically reviewed the literature in 1982 and found only five acceptable cases of anaplastic transformation. In all these cases the transformation occurred from 1.5 to eight months following radiotherapy. Batsakis et al find it difficult to believe that transformation can occur in such a short time frame and now believe that the lesion undergoing anaplastic transformation are actually "hybrid" tumors composed of verrucous carcinoma and invasive squamous carcinoma. For this reason it is now recommended that treatment be based on the overall effectiveness of the treatment and not on its anaplastic potential. And as previously mentioned surgery has given the best results and is the treatment of choice. Case Presentation A 64-year-old white male with a 50 pack per year smoking history presented to the V.A. Hospital Otolaryngology clinic complaining of a three month history of hoarseness. He denied dysphagia, sore throat or recent upper respiratory infection. On examination he had an exophytic mass on the anterior one third of his left true vocal cord. There was no impairment of true vocal cord mobility or associated lymphadenopathy. The mass was totally removed during direct laryngoscopy; and pathologic analysis revealed verrucous carcinoma. Since the mass was totally excised at the time of direct laryngoscopy no further treatment was recommended except for frequent follow-up examinations in clinic. The patient is now two months out from his surgery without evidence of recurrent disease. 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