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Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 134-137

Excisional biopsy of verrucous carcinoma of tongue using diode laser

Department of Periodontology and Oral Implantology, B.J.S. Dental College, Hospital and Research Institute, Ludhiana, Punjab, India

Date of Submission10-Oct-2020
Date of Decision20-Nov-2020
Date of Acceptance24-Dec-2020
Date of Web Publication22-Mar-2021

Correspondence Address:
Vikrant Sharma
65B/1 Lane No. 3 Raman Enclave Near Rishi Nagar, Ludhiana - 141 008, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_179_20

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Oral verrucous carcinoma (OVC) is a subtle variant of oral squamous cell carcinoma with some peculiar features. It is locally invasive growth which rarely metastasizes. Verrucous carcinoma rarely affects the tongue. Herein, we report a case of excisional biopsy of a grayish-white lesion on the left lateral surface of the tongue performed with a 940-nm diode laser, which upon histopathological examination was diagnosed as OVC.

Keywords: Diode laser, tongue, verrucous carcinoma

How to cite this article:
Sharma V, Kalsi D S, Goyal A, Singh S, Khichy A, Sood A. Excisional biopsy of verrucous carcinoma of tongue using diode laser. Indian J Dent Sci 2021;13:134-7

How to cite this URL:
Sharma V, Kalsi D S, Goyal A, Singh S, Khichy A, Sood A. Excisional biopsy of verrucous carcinoma of tongue using diode laser. Indian J Dent Sci [serial online] 2021 [cited 2021 Apr 20];13:134-7. Available from: http://www.ijds.in/text.asp?2021/13/2/134/311682

  Introduction Top

Oral verrucous carcinoma (OVC) is a slow-growing tumor, which presents predominantly as an exophytic growth with a pebbly, micronodular surface. It tends to spread locally and even advanced cases are unlikely to show metastasis. Ackerman first described the OVC as a distinct entity.[1] Various names are used in the literature to describe this entity, including Ackerman's tumor, Buschke–Lowenstein tumor, florid oral papillomatosis, epithelioma cuniculatum, and carcinoma cuniculatum.[2] The most common site of occurrence is oral cavity involving buccal mucosa, mandibular alveolar crest, gingiva, and tongue.[3]

As cancer is common, cancer screening must be done for all patients. In view of this, a thorough inspection of the oral cavity should be a part of any complete head-and-neck examination. It has been suggested that approximately 10% of patients who are examined will have some abnormalities of the oral mucosa.[4],[5],[6] Biopsy is often the definitive procedure that provides tissue for microscopic analysis when additional information is required to guide any indicated therapy.

Excisional biopsy with Bard-Parker blade is the most common way of management of premalignant or malignant lesions.[7],[8] However, postoperative hemorrhage is a common complication associated with the surgical procedures of the tongue. Alternative methods that can do away with blades, sutures, and bleeding, are likely to be more acceptable by patients. The authors present a case where excisional biopsy of a lesion on the lateral surface of the tongue was done using a 940-nm diode laser.

  Case Report Top

A male patient aged 64 years came to the department of periodontology with a chief complaint of whitish rough elevated patch on the left lateral border of the tongue for 1 year. The patient also complained of burning sensation on eating spicy food. The patient was on no medication for this lesion and gave a history of tobacco chewing for 20 years after which he had quit 10 years back. On intraoral examination, an extended grayish-white nonscrapable sessile lesion was noticed on the left lateral border of the tongue adjacent to the canine and the premolars of the left lower side. The lesion had red base and white flakes of adherent tissue (erythroplakic) anteriorly while it was white (hyperkeratotic) in its posterior half [Figure 1]. On palpation, lesion was soft and pliable. Regional lymph nodes were nonpalpable. No similar lesions were noticed elsewhere on the tongue or oral cavity. No history of tenderness or difficulty in swallowing was reported.
Figure 1: The grayish-white lesion on the left lateral surface of the tongue

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As the lesion was erythroleukoplakic and was present since a very long time (more than 1 year), suggesting that it could be a premalignant or malignant, it was decided to take a biopsy of the lesion. The patient was explained the urgency and the need for biopsy. As the patient was scared and apprehensive about surgery, sutures, postoperative bleeding, and pain, the patient was offered excision of the lesion using a soft-tissue laser machine. After attaining patient consent for biopsy, complete hemogram was ordered and the patient was scheduled for biopsy. Biopsy specimen was obtained using diode laser of wavelength 940 ± 10 nm. Local anesthesia using lingual nerve block was administered. The patient was asked to protrude his tongue, and sterile gauge pieces were used to hold the tongue and manage its movement. New sterile surgical laser tip (e-4. 21) supplied by manufacturer was used for the procedure. After activating the tip using a wooden cork, the laser tip was used to excise the lesion in a continuous wave mode using power settings of 1.2 W.

During excision, 1 mm of healthy tongue tissue on all sides was also removed along with the lesion. Tissue tagging was done using sutures with long-long suture tags on the anterior border long-short suture tags on the posterior border and short-short suture tags on the inferior border [Figure 2]. The lesion was approximately 1.8 cm × 1.5 cm in size. No bleeding was observed during the entire procedure, and the patient remained comfortable during the entire procedure. The patient was instructed to take nonspicy semisolid diet for 10 days and to take prescribed analgesics if and when required. He was asked to report to the department for the follow-up examination after 1 week. The biopsy tissue sample was put in 10% formalin solution and sent to department of oral pathology of the institute where it was histopathologically examined. Histopathological examination confirmed it as verrucous carcinoma. On the follow-up visit after 1 week, the patient reported of a mild pain and discomfort only for the first 3 days after the surgery with no bleeding and swelling of the operated site [Figure 3].
Figure 2: Sutures tags placed at three borders of the biopsy specimen for orientation of specimen. Two long suture tags at anterior border, one short and one long tag on posterior border, and two short tags on the base of specimen

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Figure 3: One-week postoperative healing of the operated site

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Histopathological findings

On microscopic examination, the hematoxylin and eosin stains sections showed well-differentiated epithelial proliferation with downgrowth of epithelium into connective tissue stroma. The epithelium was stratified squamous type and was hyperchromatic. The rete pegs were bulbous in nature with intact basement membrane and pushing margins. Cleft-like spaces were lined by a thick layer of parakeratin extending from the surface deep into the center of rete pegs. Underlying stroma was delicate and showed chronic inflammatory cells such as lymphocytes and plasma cells [Figure 4], [Figure 5], [Figure 6]. Based on the above features, it was diagnosed as verrucous carcinoma.[9] No thermal alteration of the tissue specimen was observed.
Figure 4: Photomicrograph showing downward growth of stratified squamous epithelium into the stroma along with parakeratin plugging (H and E, ×40)

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Figure 5: Photomicrograph showing pushing margins of epithelium and chronic inflammatory cells (H and E, ×10)

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Figure 6: Photomicrograph showing bulbous rete peg in cross section with parakeratin plugging in the center (H and E, ×40)

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  Discussion Top

Recognition and diagnosis of tongue abnormalities require examination of tongue morphology and a thorough history, including onset and duration, antecedent symptoms, and tobacco and alcohol use. Tongue growths usually require biopsy to differentiate benign lesions from premalignant lesions and malignant lesions.

OVC is a slow-growing lesion with exophytic growth pattern and is a variant of well-differentiated squamous cell carcinoma. The oral cavity is one of the predilection sites for verrucous carcinoma, especially buccal mucosa, alveolar ridge, and gingiva. Verrucous carcinoma has also been reported in other sites such as nasal cavity, larynx, and esophagus.[10],[11],[12]

Various techniques are used to take biopsies of patients having oral lesions that are suspected to be premalignant or malignant. Lesion depending on type, extent, and spread may be biopsied by excision using scalpel, lasers, electrosurgery, cryosurgery, and/or chemotherapy. Recently, the use of lasers has become popular. There are many advantages of using lasers over surgical methods, the primary one being no hemorrhage and no need of suturing and limiting the transplantation of malignant cells into uninvolved healthy tissues. Advantages also include sterile surgical field and accuracy. Lesions can be removed accurately with lasers, and there is minimal damage to adjacent structures.

As OVC is a locally malignant lesion that is not known to metastasize even if lesion is in advanced stage, complete excision must be done, and it might be the only treatment required, however, management after histopathological confirmation is best left to an oncologist.[6]

The use of laser for excision of these types of lesions reduces the volume of local anesthesia and provides a relatively bloodless field of operation. These are the compelling benefits of using laser for excisional biopsy over conventional surgical excision.

  Conclusion Top

The excisional biopsy using diode laser provides with a safe, painless bloodless surgical treatment option of removal of malignant lesion from the tongue. The biopsy specimen obtained did not undergo any thermal alteration due to the procedure. The use of diode laser is, therefore, recommended for surgical excisions of soft-tissue lesions of the oral cavity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery 1948;23:670-8.  Back to cited text no. 1
Schwartz RA. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol 1995;32:1-21.  Back to cited text no. 2
Murrah VA, Batsakis JG. Proliferative verrucous leukoplakia and verrucous hyperplasia. Ann Otol Rhinol Laryngol 1994;103:660-3.  Back to cited text no. 3
Regezi JA, Sciubba J. Oral pathology clinical-pathologic correlations. Philadephia, WB: Saunders Company; 1993.  Back to cited text no. 4
Koch BB, Trask DK, Hoffman HT, Karnell LH, Robinson RA, Zhen W, et al. National survey of head and neck verrucous carcinoma: Patterns of presentation, care, and outcome. Cancer 2001;92:110-20.  Back to cited text no. 5
Chen BL, Lin CC, Chen CH. Oral verrucous carcinoma: An analysis of 73 cases. Clin J Oral Maxillofac Surg 2000;11:11-7.  Back to cited text no. 6
Yoshimura Y, Mishima K, Obara S, Nariai Y, Yoshimura H, Mikami T. Treatment modalities for oral verrucous carcinomas and their outcomes: Contribution of radiotherapy and chemotherapy. Int J Clin Oncol 2001;6:192-200.  Back to cited text no. 7
Yeh CJ. Treatment of verrucous hyperplasia and verrucous carcinoma by shave excision and simple cryosurgery. Int J Oral Maxillofac Surg 2003;32:280-3.  Back to cited text no. 8
Shafer WG, Hine MK, Levy BM. Benign and malign tumors of the oral cavity. In: A Textbook of Oral Pathology. Philadelphia, WB: Saunders Company; 1983. p. 127-30.  Back to cited text no. 9
Shear M, Pindborg JJ. Verrucous hyperplasia of the oral mucosa. Cancer 1980;46:1855-62.  Back to cited text no. 10
Jordan RC. Verrucous carcinoma of the mouth. J Can Dent Assoc 1995;61:797-801.  Back to cited text no. 11
Schrader M, Laberke HG, Jahnke K. Lymphatic metastases of verrucous carcinoma (Ackerman tumor). HNO 1987;35:27-30.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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