Diagnostic Discussion Diagnostic Discussion By Drs. Indraneel Bhattacharyya and Nadim Islam A 44-year-old female was referred to Dr. Daniel Lauer, a periodontist in Palm Beach Gardens, Fla., for evaluation of a mildly symptomatic lesion on the palate (Fig. 1) by her dentist, Dr. Jimmy Chen, also of Palm Beach Gardens. The patient reported a his- tory of food-related trauma to her palate four to six weeks before the lesion appeared. She complained of mild irritation in the area, especially on food con- sumption. Her medical history was non-contributory and she reports no prior history of similar lesions. Fig. 1 She is a non-smoker. The lesion appeared slightly “bumpy” on the surface and was slightly reddish- to flesh-colored. It measured approximately 1 x 0.4 cm and was roughly rectangular in shape. Slight ery- thema was noted around the lesion. The lesion was entirely excised and submitted to the University of Florida College of Dentistry Oral Pathology Biopsy Service. The biopsy showed a papillary proliferation of epithelium with significantly thickened keratin with elongated rete ridges and foamy cells in the connec- tive tissue (Fig. 2). Question: Which of the following is the most likely diagnosis? A. Verrucous Leukoplakia B. Verruca Vulgaris C. Condyloma Acuminatum (venereal wart) D. Focal Epithelial Hyperplasia (Heck’s Disease) E. Verruciform Xanthoma Fig. 2 Please see DIAGNOSTIC, 50 www.floridadental.org May/June 2014 Today's FDA 49 Diagnostic Discussion DIAGNOSTIC from 49 ated with the human papilloma virus are mostly reported on the lingual fre- (HPV). Verruca vulgaris is associated num, soft palate and the labial mucosa, Diagnostic with HPV, HPV-2, HPV-4 and HPV- supposedly related to sites of abrasion 40. However, verrucas are typically small during oro-genital contact. Most impor- Discussion lesions measuring less than 1 cm in size, tantly, condylomas are typically clustered and oral lesions almost always appear with multiple lesions or multifocal A. Verrucous Leukoplakia to be intensely white with finger-like distribution, though isolated and solitary Incorrect. An excellent choice! This projections rising above the surrounding lesions are occasionally noted. These are entity is a definite possibility given the mucosa. In addition, verruca vulgaris is associated with human papilloma virus history of trauma. These lesions are a typically pedunculated and not sessile, as (HPV) subtypes 2, 6, 11, 53 and 54, variation of the standard “leukoplakia,” seen here. Verruca vulgaris is contagious and are usually detected in the lesion. or white patch, and are typically covered and can spread to other parts of a per- The virus infects the epithelial cells, by a significantly thickened, somewhat son’s skin or mucous membranes by way multiplies and induces the epithelium to “bumpy” or verrucoid layer of ortho- or of autoinoculation. It is uncommon on proliferate. Oral lesions as large as 3-4 parakeratin. The most important distinc- the oral mucosa but extremely common cm have been reported. They are usually tion from this case is the color of the on the skin. These are frequently seen treated by conservative surgical excision. lesion; verrucous or verrucoid leukopla- in children on the skin of the hands. Laser ablation also has been used, but kia tends to be white in color due to the The oral lesions are usually located on this treatment has raised questions as thick keratin layer, and not mucosal or the vermillion border of the lips, labial to the airborne spread of HPV through normal colored or reddish as seen here. mucosa or anterior tongue. They present the aerosolized microdroplets created by Clinically, these lesions feel “bumpy” on as painless, raised papillary lesions and the vaporization of lesional tissues. Even palpation and appear white like other may occur in clusters, especially on the after excision they have been known leukoplakic lesions. Verrucous leukopla- skin. Sites of abrasion on the skin, such to recur in crops. Another important kia tends to be premalignant in nature as elbows or knees, often are affected. distinction point between this entity and and may be reactive, typically associated The recommended treatment for oral le- the correct diagnosis is microscopic. The with chronic trauma. Traumatic verru- sions is surgical excision. The majority of presence of foamy macrophages rules out cous keratosis is often seen on the man- the skin lesions disappear spontaneously the diagnosis of condylomas. dibular retromolar pad areas and on the within two years, especially in children. edentulous alveolar ridge, either where D. Focal Epithelial the soft tissue bears the brunt of masti- C. Condyloma Acuminatum Hyperplasia cation or under a denture. In this case, (venereal wart) (Heck’s Disease) there was a history of trauma, making Incorrect. Excellent guess! Condylo- Incorrect. Though these are papil- this a very possible consideration in the mas are papillary growths that can occur lary lesions, focal epithelial hyperplasia differential diagnosis. Generally, verru- anywhere on the oral mucosa. As in (FEH), also known as Heck’s Disease, cous leukoplakia is seen in an older age this case, they can be sessile with short are classically multifocal papillary le- group and is usually completely asymp- fronds, or blunted or short elevations sions. This is an uncommon disease tomatic. Microscopically, though the somewhat similar to the present case. affecting the oral mucosa and associated thickened keratin layer is seen in both Condylomas are larger than verruca and with HPV-13 (rarely HPV-32). These verrucous leukoplakia and the actual average about 1.5-2 cm. These are usu- are often reported in children of Native diagnostic entity, foamy macrophages ally reported in young individuals less American, Eskimo or African descent. are not seen with verrucous leukopla- than 25 years of age, but people of all Since it is almost always reported in kia. When seen on high-risk locations, ages are susceptible. Typically, it appears childhood, and typically resolves and verrucous leukoplakias are worrisome as a sessile, pink, well-demarcated, non- spontaneously regresses as the child ages, and usually the recommended therapy tender exophytic mass with short blunt- this diagnosis should not be considered is complete excision with close clinical ed surface projections. Condylomas, also for isolated papillary lesions in adults follow-up. called venereal warts, are one of the most without additional history. Rare but common sexually transmitted diseases usually persistent cases of FEH have B. Verruca Vulgaris (STDs), representing about 20 percent been reported in young and middle aged Incorrect. Again a very good guess! of all STDs reported in clinics. These are adults. It appears as multiple soft, non- Verrucas are benign, hyperplastic most often found on the external geni- tender, flattened or rounded mucosal growths of surface epithelium associ- talia, and are seen in the oral mucosa of or normal colored papules, which are sexually active individuals. Oral lesions usually clustered. Lesions typically occur 50 Today's FDA May/June 2014 www.floridadental.org Diagnostic Discussion on the labial, buccal and lingual mucosa. metabolic or systemic disease. The key to Diagnostic Discus- They also may be scattered, pale and the diagnosis is recognizing the papil- sion is contributed rarely white. Individual lesions are small, lary surface that is characteristic of these by UFCD profes- discrete and well-demarcated, but they lesions. These lesions also can be um- sors, Drs. Nadim frequently cluster so closely together that bilicated with a cratered center but they Islam, Indraneel the entire area takes on a cobblestone or usually are papillary within the depressed Bhattacharyya and fissured appearance. Spontaneous regres- center very similar to this case. They sion of lesions has been reported after also have a characteristic white, yellow- Don Cohen, and months or years, and is inferred from the white, or reddish-orange color (seen in provides insight and rarity of the disease in adults. Micro- the present case). This color is thought feedback on com- scopic examination of the lesion, similar to reflect collections of large numbers of Dr. Islam mon, important, to the other entities discussed here, lipid-laden or foamy macrophages (Fig. new and challeng- does not exhibit foamy macrophages. 2) found ubiquitously in this lesion. ing oral diseases. Conservative surgical incision may be Hyperkeratosis, elongated rete ridges and performed for diagnosis or aesthetic pur- collections of these foamy macrophages The dental profes- poses, or for lesion subjected to recurrent are all required for the histologic diag- sors operate a large, trauma. nosis of this lesion. The papillary surface (verrucous) and presence of abundant multi-state biopsy E. Verruciform Xanthoma lipid-containing foam cells (xanthoma) service. The col- Correct! Verruciform xanthomas are give this lesion its name. The lesions are umn’s case studies relatively uncommon lesions of the oral totally innocuous and are thought to be Dr. Bhattacharyya originate from the mucosa. They occur most frequently associated with trauma and/or chronic more than 10,000 on the gingivae, especially the marginal irritation, which was part of the history specimens the gingiva, the alveolar mucosa and the in this case. They are treated by simple service receives every excision and usually do not recur. palate, but can be found on any masti- year from all over catory surface. They are most common the United States. in Caucasians in the age group of this Useful References patient (40-60 years of age). A strong 1. Allen CM, Kapoor N. Verruciform xan- Clinicians are female predilection is reported, which thoma in a bone marrow transplant recipient. is supported in this case. They also have Oral Surg Oral Med Oral Pathol. 1993 May; invited to submit 75(5):591-4. been described on the skin, esophagus Dr. Cohen cases from their own 2. Hu JA, Li Y, Li SVerruciform xanthoma practices.