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Verrucous hyperplasia



Q&A: What is Oral Verrucous Hyperplasia?

Author: Sanketh DS, MDS

Shear and Pindborb in 1980 reported lesions of the oral cavity that were clinically indistinguishable from verrucous carcinoma (VC) but showed slight differences under the microscope. They called them “Verrucous Hyperplasia” (VH). According to them, VH was best distinguished from VC by its broad rete ridges that were in level with the adjacent normal epithelium, not extending deep into the lamina propria.

However, there has always been confusion with regards to the diagnosis and terminology of this lesion. And in order to bring some uniformity in reporting this lesion, an expert group of Oral Pathologists held a consensus meeting in Malaysia in 2013. They formulated a set of clinico-pathologic features and proposed the term “Exophytic Verrucous Hyperplasia”.

EVH clinically, is a solitary white or pink verrucous & exophytic growth greater than 1 cm in size. Since its main etiology is betel quid chewing, it could manifest in conjunction with oral submucous fibrosis. Apart from these features, EVH has been reported to manifest at a mean age of 54 and predominantly on the buccal mucosa. However, care is to be taken while diagnosing this entity, as it resembles verrucous carcinoma and squamous cell carcinoma.

Histologically, EVH may resemble VC but shows minor differences. It shows a hyperkeratotic and a hyperplastic epithelium (usually parakeratosis), with the surface of the lesion having exophytic, verruciform projections. There may be depressions or clefts in the epithelium between surface projections, referred to as parakeratin plugs. However it mainly differentiates itself from VC in the absence of an endophytic growth of the epithelium. The broad rete ridges are rather in the same level as the adjacent normal epithelium and do not extend deep into the connective tissue unlike VC. The other difference is the presence of epithelial dysplasia. But, note that dysplasia may not be always present. Certain lesions are also accompanied by a sub-epithelial lymphocytic infiltrate.

As for the prognosis, EVH has shown to manifest with dysplasia and also transform to verrucous carcinoma and squamous cell carcinoma. It has in fact been reported to be a distinct entity in the Indian population and some pathologists consider it to be a potentially malignant disorder, though it has not been classified as one by the WHO. It is best to treat this lesion like VC and completely excise the lesion.

REFERENCES

Shear M, Pindborg JJ. Verrucous hyperplasia of the oral mucosa. Cancer 1980; 46: 1855–62.

Zain RB, Kallarakkal TG, Ramanathan A, et al. A consensus report from the first Asian regional meeting on the terminology and criteria for verucco-papillary lesions of the oral cavity held in Kuala Lumpur, Malaysia. Ann Dent Univ Malaya 2013; 20: 1–3.

Patil S, Warnakulasuriya S, Raj T, Sanketh DS, Rao RS. Exophytic oral verrucous hyperplasia: a new entity. J Investig Clin Dent. 2016;7(4):417-423.

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