Exophytic warty white plaque of the buccal mucosa in a tobacco chewer
63-year-old male
§Chief complaint
Rough, thick white growth inside the cheek for 2 years
§Medical & dental history
- 01Chews betel quid with tobacco 8 times daily for 30 years
- 02Type 2 diabetes
- 03Quid habitually held in the right buccal sulcus
§Clinical examination
- 01Broad, exophytic, warty white plaque 40 mm with a pebbly surface over the right buccal mucosa
- 02Soft to firm, no induration of the base; no ulceration
- 03No trismus; mouth opening 42 mm
- 04No palpable cervical lymphadenopathy
§ figuresFigures (3)
Fig. 1Micrograph of penile verrucous carcinoma. The tumor is characterized by prominent papillomatosis and acanthosis [haematoxylin-eosin stain, original magnification x20].
“Micrograph of penile verrucous carcinoma - 20x” · Prodromos Philippou, Christos Kitsios, Maria Miliatou, Christiana Poullou, and P · CC BY 4.0 · Wikimedia Commons
Fig. 2Micrograph of penile verrucous carcinoma. The tumor front is broad-based and pushes the subepithelial tissues [haematoxylin-eosin stain, original magnification x200].
“Micrograph of penile verrucous carcinoma - 200x” · Prodromos Philippou, Christos Kitsios, Maria Miliatou, Christiana Poullou, and P · CC BY 4.0 · Wikimedia Commons
Fig. 3Low power, showing "pushing" of tumor into underlying tissue. There is lots of scarring and chronic inflammation in the underlying tissue. Pathological and histological images courtesy of Ed Uthman at flickr.
“Verrucous Carcinoma 4 (146950404)” · Ed Uthman from Houston, TX, USA · CC BY 2.0 · Wikimedia Commons
Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Verrucous Carcinoma figures pending faculty review.
§Differential diagnosis
§Final diagnosis
Verrucous carcinoma of the right buccal mucosa
A broad warty plaque without induration in a long-standing tobacco chewer, with histology showing thick club-shaped keratinised rete ridges pushing into the underlying tissue with minimal atypia and an intact basement membrane, is verrucous carcinoma rather than conventional SCC.
§Investigations
- 01Generous deep incisional biopsy including the base — superficial biopsy is often non-diagnostic
- 02Careful examination of the whole mucosa for synchronous lesions
- 03MRI if deep extension is suspected
§Radiology
- 01OPG — no bone involvement
- 02MRI — lesion confined to mucosa and submucosa, no muscle invasion
§Treatment plan
- 01Wide local surgical excision with clear margins
- 02Complete cessation of betel quid and tobacco with counselling support
- 03Long-term surveillance for field change and recurrence
§Surgical procedure
- 01Wide local excision of the plaque with 10 mm margins; defect reconstructed with a buccal fat pad flap
§Histopathology report
Markedly thickened, heavily keratinised squamous epithelium with broad, blunt, club-shaped rete processes pushing into the lamina propria; parakeratin plugging, minimal cytological atypia, intact basement membrane, dense chronic inflammatory infiltrate at the interface. Verrucous carcinoma; margins free.
§Follow-up & outcome
- 016 weeks — healed with good mouth opening
- 023-monthly review for 2 years; habit stopped at 3 months
- 03No recurrence at 24 months
Outcome: Local control achieved with surgery alone; patient quid-free at 2 years.
§Discussion
- 01Verrucous carcinoma does not metastasise, so surgery alone is usually curative; neck dissection is not routine.
- 02Up to 20% of lesions harbour foci of conventional SCC, which is why a deep, generous biopsy matters.
- 03Radiotherapy is avoided where possible because of historical concerns about anaplastic transformation.
§Clinical pearls / learning points
- 01A superficial biopsy of a warty lesion often reads as hyperkeratosis — go deep and include the interface.
- 02Ackerman tumour is the eponym; think betel quid and snuff-holding sites.
§Viva questions
How does verrucous carcinoma differ histologically from conventional SCC?
Pushing rather than infiltrating margins, broad club-shaped rete ridges, minimal atypia and an intact basement membrane.
Does it metastasise?
Essentially never; regional nodes are usually reactive rather than metastatic.
§MCQs
Q1Verrucous carcinoma is also known as:
Q2Treatment of choice for verrucous carcinoma is:
§ evidenceReferences & Evidence
Current Classification
WHO Classification of Head and Neck Tumours
5th Edition — Volume 9
WHO Classification of Tumours Editorial Board · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
Evidence summary
Highest level of evidence linked to this page: WHO / Official Classification.
- L1 · Classification — 2
- L6 · Textbook — 3
1 linked source was published from 2024 onwards. Where guidance is limited or contested, rely on the higher-level sources above rather than this summary. Educational use only — not a substitute for clinical judgement.
Content last reviewed
September 2026
Evidence last reviewed
September 2026
Next scheduled review
September 2027
Review status
EVIDENCE REVIEWED
Search latest PubMed evidence
Last literature search: 7 September 2026
Current Classification
WHO Classification of Tumours Editorial Board. IARC / World Health Organization · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
IARC / WHO. IARC · 2022
Continuously updated online edition of the WHO head and neck tumour classification.
Histopathology References
Barnes L. CRC Press · 2008
Detailed histopathological reference for head and neck diagnostic criteria.
Textbook References
Neville BW, Damm DD, Allen CM et al.. Elsevier · 2024
Standard reference textbook of oral and maxillofacial pathology used throughout this atlas.
Rajendran R, Sivapathasundharam B. Elsevier · 2020
Undergraduate and postgraduate oral pathology textbook widely used in BDS and FCPS curricula.
Additional sources cited on this page
- WHO Classification of Head and Neck Tumours, 5th edition, 2022.
- Walvekar RR et al. Verrucous carcinoma of the oral cavity. Oral Oncol 2009.
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