How to follow up on a patient with a potential diagnosis of verrucous (squamous cell) carcinoma and a red patch on the tongue?

Management of Verrucous Carcinoma with Red Patch on the Tongue

For a patient with suspected verrucous carcinoma and a red patch on the tongue, a comprehensive diagnostic workup followed by appropriate surgical management is essential to reduce morbidity and mortality.

Diagnostic Approach

• Red patches on the tongue that persist for more than 2 weeks require biopsy for definitive diagnosis, especially when associated with verrucous carcinoma 1, 2
• Clinical evaluation must include complete physical examination with neck palpation, flexible head and neck fibreoptic endoscopy, performance status assessment, nutritional status evaluation, and dental examination 1
• Pathological confirmation is mandatory through examination and biopsy, which can be performed transorally under local anesthesia 1
• Laboratory tests should include complete blood count, liver enzymes, serum creatinine, albumin, coagulation parameters, and thyroid-stimulating hormone (TSH) 1, 2

Imaging Studies

• Contrast-enhanced CT scan and/or MRI are mandatory to assess the primary tumor and regional lymph nodes 1
• Chest imaging is important to assess for distant metastases, particularly in high-risk tumors with neck adenopathies 1
• FDG-PET/CT is recommended for evaluation of neck response to treatment or in cases of suspected recurrence 1

Pathological Assessment

• Verrucous carcinoma typically appears as an exophytic, well-differentiated variant of squamous cell carcinoma with warty or cauliflower-like growth 3, 4
• Histopathological diagnosis can be challenging, often requiring multiple biopsies for confirmation 4, 5
• Pathological assessment should include size of tumor, growth pattern, depth of invasion (for oral cavity cancer), presence of perineural and lymphatic infiltration 1
• Verrucous carcinoma may transform into invasive squamous cell carcinoma in long-standing cases, requiring careful histopathological examination 5, 6

Treatment Plan

• Surgical excision is the treatment of choice for verrucous carcinoma of the tongue 3, 4
• The extent of surgery should be determined based on tumor size, location, and depth of invasion 1
• For patients with risk factors such as positive margins, perineural infiltration, or lymphovascular spread, postoperative radiotherapy should be considered 1
• Postoperative radiotherapy should be started within 6-7 weeks after surgery, and the complete treatment regimen should be delivered within 11 weeks 1

Follow-up Protocol

• Regular follow-up examinations are essential due to the high possibility of recurrent disease 4
• FDG-PET is recommended to evaluate the neck response to radiotherapy or chemoradiotherapy 10-12 weeks after completing treatment 1
• Monitor for development of second primary tumors, particularly in patients with risk factors such as tobacco and alcohol use 1

Special Considerations

• Verrucous carcinoma has been reported to occur on lesions of lichen planus, requiring careful monitoring of patients with oral lichen planus 7
• The role of radiation therapy in treatment of oral verrucous carcinoma is controversial, with adequate surgical excision appearing to be the primary treatment of choice 3
• In cases of recurrence, additional chemotherapy may be necessary to prevent further recurrences 7

Pitfalls to Avoid

• Delay in diagnosis due to the slow-growing nature of verrucous carcinoma can lead to extensive local invasion 4
• Misdiagnosis is common due to the well-differentiated appearance of the tumor, requiring experienced pathological interpretation 5
• Underestimating the extent of the lesion can lead to inadequate surgical margins and recurrence 4