What is the primary treatment for verrucous carcinoma of the buccal mucosa?

Primary Treatment for Verrucous Carcinoma of the Buccal Mucosa

Wide local surgical excision is the primary treatment of choice for verrucous carcinoma of the buccal mucosa, with adequate tumor-free margins to ensure complete removal of the lesion. 1, 2, 3, 4

Characteristics of Verrucous Carcinoma

• Verrucous carcinoma is a rare variant of squamous cell carcinoma, comprising approximately 5% of all oral malignancies 2
• It is characterized by slow, relentless growth and a low metastasis rate 1
• The buccal mucosa is the most common site of occurrence within the oral cavity, followed by the mandibular alveolar ridge, gingiva, and tongue 3, 4

Surgical Management

• Wide local excision is the standard first-line treatment with reported success rates of 100% in some studies 4
• Surgical margins vary in the literature from 0.5-3.0 cm, with recurrence rates ranging from 4.6-75.0% depending on adequacy of margins 1
• Mohs Micrographic Surgery has been used especially for recurrent tumors, with an overall recurrence rate of 12.9% 1
• En bloc resection of the primary tumor should be attempted whenever feasible to ensure complete removal 5

Preoperative Assessment

• A complete head and neck examination with appropriate imaging studies is essential for accurate staging 5
• Imaging studies to evaluate mandibular involvement and careful dental evaluation are particularly important for planning therapy 5
• For patients with suspected advanced disease, PET-CT may alter management by identifying additional disease sites 5

Management of Lymph Nodes

• Regional lymph node dissection is usually not necessary due to the low metastatic potential of verrucous carcinoma 2, 4
• Even in advanced stages, elective neck dissection is generally not required as the risk of lymph node metastasis is very low 4
• For oral cavity cancers in general, if definitive radiotherapy is chosen for treatment of T1-2, N0 disease, at least 44-64 Gy is given to the neck 5

Radiotherapy Considerations

• The role of radiation therapy in verrucous carcinoma is controversial 3
• Some studies have reported concerns about anaplastic transformation after radiotherapy, though this has been disputed by other research 6
• A study of 53 patients with oral verrucous cancers showed complete response to radiotherapy in 76% of patients with no evidence of anaplastic transformation in recurrent cases 6
• If surgery is not feasible due to patient factors or tumor extent, radiotherapy may be considered as an alternative treatment 6

Postoperative Management

• Postoperative radiotherapy should be considered for cases with adverse pathologic features such as positive margins 5
• Close follow-up is recommended due to the potential for local recurrence 2
• The overall prognosis is generally good with appropriate surgical management, with five-year survival rates reported as high as 86% 6

Treatment Pitfalls and Caveats

• Histologically, verrucous carcinoma can present a diagnostic dilemma as the basement membrane is often intact, which may lead to misinterpretation as hyperkeratosis and severe dysplasia 2
• Inadequate surgical margins are associated with higher recurrence rates, emphasizing the importance of complete excision 1
• Tissue-sparing approaches should be considered given the sensitive locations often involved, but not at the expense of complete tumor removal 1
• Multidisciplinary team involvement is particularly important for oral cavity tumors because of the critical physiologic functions of mastication, deglutition, and articulation of speech 5