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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 34  |  Issue : 4  |  Page : 481-483

A diagnostic challenge of growth on the tongue in geriatric patient—A rare case report


Department of Oral Medicine and Radiology, Tamil Nadu Government Dental College and Hospital affiliated to the Tamil Nadu Dr.M.G.R. Medical University, Tamil Nadu, India

Date of Submission06-Oct-2021
Date of Decision02-Feb-2022
Date of Acceptance23-Oct-2022
Date of Web Publication09-Dec-2022

Correspondence Address:
Anitha Palanisamy
Department of Oral Medicine and Radiology, Tamil Nadu Government Dental, College and Hospital, Chennai - 600 003, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_291_21

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   Abstract 


Verruciform xanthoma (VX) is an uncommon benign inflammatory mucocutaneous condition of uncertain etiopathology which occurs on the oral mucosa. Histologically, VX is distinguished from other lesions by the presence of large numbers of foam cells in connective tissue papillae. The treatment of the VX one involves local surgical excision, and recurrence is rare. An 82-year-old male patient presented with a painless growth in the tongue for the past year. On clinical examination, a white exophytic lesion was found on the right lateral border of the tongue, and a solitary cauliflower-like growth was seen on the left ventral surface of the tongue, which was painless on palpation. That was provisionally diagnosed as squamous papilloma on the left side and verrucous carcinoma on the right side. This case report describes an unusual case of two different lesions present in the tongue that have features of VX and squamous cell carcinoma.

Keywords: Oral verruciform xanthoma, squamous cell carcinoma, xanthoma cells


How to cite this article:
Sadaksharam J, Kathiresan I, Vimal SJ, Palanisamy A. A diagnostic challenge of growth on the tongue in geriatric patient—A rare case report. J Indian Acad Oral Med Radiol 2022;34:481-3

How to cite this URL:
Sadaksharam J, Kathiresan I, Vimal SJ, Palanisamy A. A diagnostic challenge of growth on the tongue in geriatric patient—A rare case report. J Indian Acad Oral Med Radiol [serial online] 2022 [cited 2023 Feb 3];34:481-3. Available from: http://www.jiaomr.in/text.asp?2022/34/4/481/363031




   Introduction Top


Verruciform xanthoma (VX) is a rare benign lesion of unknown etiology. As per Buchner's report, the incidence rate of VX is 0.025–0.095% in the oral cavity within 12 years.[1] VX is associated with other conditions, such as leukoplakia, oral squamous cell carcinoma, lichen planus, and oral submucous fibrosis which are rare. Only two cases of VX associated with squamous cell carcinoma were reported earlier. Clinically, it has been described as a papillary, flat, or verrucous lesion with either a pedunculated or broad base. The treatment of the lesion involves local surgical excision, and recurrence is rare.[2] Squamous cell carcinoma of the tongue is the most common oral cancer, usually occurring in the lateral border of the tongue.[3] This is a case report of an unusual presentation of VX on the ventrolateral surface and squamous cell carcinoma on the lateral border of the tongue in an 82-year-old male.


   Case History Top


Patient information

An 82-year-old male patient reported to the Department of Oral Medicine and Radiology with a chief complaint of painless growth on the tongue for the past 1 year. He also had a history of a burning sensation present in the dorsum of the tongue. His past medical history revealed a history of hypertension, and he has been under medication for the past ten years. Past dental history revealed a history of extraction 10 years back. His personal history revealed a habit of smoking four to six cigarettes per day for 35 years, and he quit the habit of smoking around 5 years back.

Clinical description

On general examination, the patient was well-built and moderately nourished. Intraoral examination revealed a solitary cauliflower-like growth was seen on the left ventrolateral surface of the tongue in relation to 36 and 37, measuring about 1 × 1 cm in size [Figure 1]a, soft to firm in consistency, non-tender, and not fixed to the underlying mucosa. An exophytic growth measuring about 2 × 1 cm in size, rough surface, soft to firm in consistency, and non-tender was seen on the right lateral border of the tongue in relation to 45,46, and 47 [Figure 1]b. No regional lymph nodes were palpable.
Figure 1: (a) Image showing verrucous growth in the left ventrolateral surface of tongue, (b) Image showing exophytic growth in the right lateral border of tongue, (c) Image showing verrucous growth in the left ventrolateral surface of tongue (white arrow) exophytic growth in the right lateral borders of tongue (black arrow)

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Diagnostic assessment

Based on the history and clinical examination, the lesion on the right side of the tongue was provisionally diagnosed as verrucous carcinoma. The lesion on the left side of the tongue was provisionally diagnosed as squamous papilloma [Figure 1]c. Differential diagnosis included verruciform xanthoma, verrucous carcinoma, and squamous cell carcinoma. Complete blood count, blood sugar, renal function test and liver function test, ECG, and prothrombin time were performed. The biochemical parameters were within the normal range.

Therapeutic intervention

Both lesions were excised under local anesthesia within an interval of one month [Figure 2]a and [Figure 2]b. Microscopic examination of the excised specimen from the left side of the lesion showed central exophytic epithelial proliferation with thinned-out long narrow rete pegs extending into connective tissue papilla. It contained lipid-laden foamy macrophages [Figure 3]a. The lamina propria showed chronic inflammatory cells. The excised specimen from the right lateral border of the tongue showed hyperplastic and dysplastic surface epithelium exhibiting parakeratosis, broad, bulbous rete process, and sheets with keratin differentiation [Figure 3]b. Connective tissue was seen entrapped within the epithelial differentiation. The confirmatory diagnosis of the lesion from the left ventrolateral surface of the tongue was verruciform xanthoma, and the right lateral border of the tongue was well-differentiated squamous cell carcinoma.
Figure 2: (a) Intraoperative image showing complete excision of the growth in left lateral border of tongue, (b) Intraoperative image showing complete excision of the growth in right lateral border of tongue, (c) Image showing one month after excision of growth in the left ventrolateral surface of tongue, (d) Image showing one week after excision of growth in the right lateral border of tongue

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Figure 3: (a) Image showing the connective tissue papillae contained lipid laden foamy macrophages also known as xanthoma cells (Hematoxylin and Eosin,×40) arrow indicating foam cells, (b) Image Showing well-differentiated squamous cell carcinoma (H and E, ×40), black arrow indicating sheets with keratin differentiation

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Follow-up and outcomes

The patient was recalled for a follow-up; there were no signs of recurrence on both sides so far [Figure 2]c and [Figure 2]d. In the follow-up period, the patient was advised for removal of 43,44,45 due to the presence of sharp cusps.

Timeline of history




   Discussion Top


Verruciform xanthoma is a unique oral lesion that usually appears on masticatory gingival mucosa, but it was seen on the tongue in this case. The epithelial breakdown causes an inflammatory response and a subsequent release of lipid material from the degenerated cells.[4] Zegarelli et al.[5] suggested that the accumulation of lipid-containing macrophages may arise from epithelial cell degeneration with the release of the lipid material, which is scavenged by the macrophages. The second hypothesis was given by Nowparast et al.[6] reported that the verrucous and papillary epithelial architecture seen in VX is probably due to the presence of foamy cells, which affect the metabolism of the epithelial cells, causing hyperkeratotic change. In this case, the inflammatory reaction from chronic mechanical irritation that resulted from the sharp cuspal margin of mandibular teeth caused papillary epithelial growth. The differential diagnosis of verruciform xanthoma is oral squamous papilloma, papillary hyperplasia, and condyloma acuminatum.[7] As a significance of VX rarity and the resemblance of its clinical features to papillary lesions, reporting cases is valuable for the prevention of their overdiagnosis. Oral verruciform xanthoma is a benign lesion that can be managed by conservative excision. Generally, it does not recur after excision. More than 95% of the carcinomas occurring in the oral cavity are squamous cells in nature. The main risk factors for the onset of oral carcinoma are tobacco and alcohol consumption, betel nut, certain dietic habits, genetic factors, sun exposure, and human papillomavirus (HPV) infection.[8] Histopathologically, squamous cell carcinoma exhibits invasive islands and cords of malignant epithelial cells with variable keratinization. Early-stage tongue cancer is generally treated with surgery (partial glossectomy) or radiotherapy (brachytherapy); however, advanced tongue cancer needs wide excision and reconstructive surgery. This case report described the rare and unusual two different lesions of OVX and the tongue's well-differentiated oral squamous cell carcinoma.


   Conclusion Top


This case showed two different lesions (benign and malignant) found on the tongue of the same patient. A biopsy is mandatory for a confirmatory diagnosis, particularly when it occurs at high-risk sites for squamous cell carcinoma development, such as the lateral border or ventral surface of the tongue. Understanding clinical and histopathological findings is essential for early diagnosis, differentiation from similar oral lesions and early treatment, and good prognosis.

Patient perspective

“I had good interaction with the physician during all the procedures, and I am satisfied with the treatment outcome as my symptoms improved.” I am not willing to undergo invasive treatment (surgery and chemoradiation) for cancer because of my age and the potential therapeutic complications.

Key message

This case report describes the bilateral presentation of rare and unusual lesions of benign and malignant nature on the tongue.

Declaration of patient consent

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

Acknowledgements

Authors acknowledge the Department of Oral Pathology, Tamil Nadu Government Dental College and Hospital, Chennai, Tamil Nadu, India, for histopathological examination of tissue.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Buchner A, Hansen LS, Merrell PW. Verruciform xanthoma of the oral mucosa: Report five cases and review of the literature. Arch Dermatol 1981;117:563-5.  Back to cited text no. 1
    
2.
Rajendran R. Shafer's Textbook of Oral Pathology. Elsevier India; 2009.  Back to cited text no. 2
    
3.
Okubo M, Iwai T, Nakashima H, Koizumi T, Oguri S, Hirota M, et al. Squamous cell carcinoma of the tongue dorsum: Incidence and treatment considerations. Indian J Otolaryngol Head Neck Surg 2017;69:6-10.  Back to cited text no. 3
    
4.
Capocasale G, Panzarella V, Tozzo P, Mauceri R, Rodolico V, Lauritano D, et al. Oral verruciform xanthoma and erythroplakia associated with chronic graft-versus-host disease: A rare case report and review of the literature. BMC Res Notes 2017;10:631.  Back to cited text no. 4
    
5.
Zegarelli DJ, Zegarelli-Schmidt EC, Zegarelli EV. Verruciform xanthoma: Further light and electron microscopic studies, with the addition of a third case. Oral Surg Oral Med Oral Pathol 1975;40:246-56.  Back to cited text no. 5
    
6.
Nowparast B, Howell FV, Rick GM. Verruciform xanthoma: A clinicopathologic review and report of fifty-four cases. Oral Surg, Oral Med, Oral Pathol 1981;51:619-25.  Back to cited text no. 6
    
7.
Sadaksharam J, Joshi B. Multiple papillomas in the oral cavity of a six-year-old child. Indian J Med Res 2019;149:680-1.  Back to cited text no. 7
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8.
Llewellyn CD, Johnson NW, Warnakulasuriya KA. Risk factors for squamous cell carcinoma of the oral cavity in young people—A comprehensive literature review. Oral Oncol 2001;37:401-18.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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