Oral cavity & oropharynx

• M > F (J Oral Pathol Med 1993;22:113)
• Wide age range, although more frequent in younger populations

• HPV is thought to gain access to epithelial cells via microabrasion or trauma (Head Neck Pathol 2019;13:80, Rev Med Virol 2015;25:2)
• Virus infects the basilar epithelial stem cells via endocytosis
• Cell division occurs during wound / trauma repair, populating the basal cell layer with transiently amplifying cells with HPV genomes
• There is slow division of the infected basal stem cells with little or no viral gene expression within the basal layer (Rev Med Virol 2015;25:2)
• Transformation of verruca vulgaris to HPV related squamous cell carcinoma is not possible since low risk HPV strains lack oncogenic properties (Rev Med Virol 2015;25:2)

• Histopathologic examination of excisional specimen
• Presence of HPV has been detected via immunohistochemical staining, electron microscopy, in situ hybridization and polymerase chain reaction studies; however, these studies are unnecessary for diagnosis (J Oral Pathol Med 1993;22:113)

• Excision (via surgery, cryosurgery or electrosurgery)
• Spontaneous regression has been reported (Dent Clin North Am 2014;58:385)

Contributed by Molly Housley Smith, D.M.D. and Michael Piepgrass, D.M.D., M.S.

Contributed by Molly Housley Smith, D.M.D.

• Wenig: Atlas of Head and Neck Pathology, 3rd Edition, 2015, Neville: Oral and Maxillofacial Pathology, 4th Edition, 2015

The lesion shown above is found on the tongue. What is the diagnosis?

1. Condyloma acuminatum
2. Squamous papilloma
3. Verruca vulgaris
4. Verrucous carcinoma

C. Verruca vulgaris. The microscopic images show a well circumscribed, papillary epithelial proliferation with inward cupping of the rete ridges, prominent koilocytosis and prominent keratohyaline granules, which are all features of verruca vulgaris. Answers A and B are incorrect because condyloma acuminatum and squamous papilloma both lack prominent hypergranulosis while condyloma acuminatum exhibits broad, blunted papillary projections rather than the thin, hyperkeratotic projections seen above. Answer D is incorrect because verrucous carcinoma demonstrates broad, pushing rete ridges and lacks circumscription.

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Reference: Verruca vulgaris

A patient presents with a white lesion on the hard palate. Microscopic examination shows a well defined proliferation of stratified squamous epithelium forming exophytic papillary fronds. The epithelium is covered by a thickened layer of dense orthokeratin, which forms church spires and hypergranulosis and koilocytosis are appreciated. The rete ridges demonstrate prominent inward cupping. What is the diagnosis?

1. Condyloma acuminatum
2. Proliferative verrucous leukoplakia
3. Verruca vulgaris
4. Verrucous carcinoma

C. Verruca vulgaris. Verruca vulgaris is characterized by a papillary epithelial proliferation with hypergranulosis, inward cupping of the rete ridges and koilocytosis, as described in the question. Answer A is incorrect because condyloma acuminata are not bright white clinically and lack prominent hypergranulosis. Answer B is incorrect because proliferative verrucous leukoplakia may look very similar to verruca vulgaris on small biopsies but proliferative verrucous leukoplakia is not well circumscribed clinically and not isolated. Additionally, proliferative verrucous leukoplakia does not show circumscription and inward cupping of the rete ridges histopathologically. Answer D is incorrect because verrucous carcinoma is traditionally larger clinically and demonstrates a pushing pattern of invasion without circumscription.

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Reference: Verruca vulgaris