Tobacco appears to be a major factor in causation of verrucous lesions. In Chen et al��s14 study of verrucous carcinomas in Taiwan, areca quid chewing was reported by 97.3%. In Chung et al��s11 study, the prevalence of verrucous lesions (not carcinomas) was 0.84%, and the frequency of current areca quid chewing in this subgroup was 55.6% (5/9). The data indicate that, in Taiwan, areca quid use could be a major risk factor in verrucous lesions. In our patients, cigarette smoking seemed the most causative factor among those mentioned above. Verrucous hyperplasia and verrucous carcinoma are indistinguishable clinically.4,7 The clinical association with leukoplakia is significant, and the evidence indicates that untreated leukoplakia may develop into a verrucous hyperplasia and/or a verrucous carcinoma in time.

Leukoplakia, in fact, is a clinical provisional designation for a keratotic white mucosal lesion whose diagnosis cannot be ascertained on clinical grounds, and that therefore requires a biopsy. The biopsy can reveal any one of many possible diagnoses, including a benign keratosis, a precancerous epithelial lesion such as chronic candidosis, and lichen planus. Shear and Pindborg3 noted that 36 of 68 patients had verrucous hyperplasia associated with leukoplakic lesions. Similarly, our study revealed one patient having verrucous hyperplasia accompanied by leukoplakic lesions. It is often difficult to distinguish between verrucous hyperplasia and verrucous carcinoma. Verrucous hyperplasia is a forerunner of verrucous carcinoma, and transition is so consistent that the hyperplasia, once diagnosed, should be treated as verrucous carcinoma.

10 Verrucous hyperplasia warrants close clinical follow-up to intercept and prevent such a possibility. Differential diagnosis can be made histologically, but a biopsy specimen should be sufficient for correct diagnosis. Verrucous hyperplasia generally does not extend into deeper tissues but is superficial to normal epithelium, whereas verrucous carcinoma extends more deeply.3,4,7 In one of our cases, the preliminary diagnosis was verrucous hyperplasia following the incisional biopsy, whereas final diagnosis was verrucous carcinoma following the excisional biopsy. Another patient was diagnosed with verrucous keratosis in initial biopsy, but the final diagnosis of all patients was verrucous carcinoma.

In our cases, histopathologic appearance was concurrent with those mentioned in the literature. In spite of the 4:1 female/male ratio in Hansen et al��s15 study and an approximately equal sex distribution in other studies, in our study, this ratio was 1.4:1 male/female. In the current literature,16 although the most common site for verrucous carcinoma is the buccal Anacetrapib mucosa, the most affected areas in the present study were the mandibular retromolar and molar area (41.6%) followed by the buccal mucosa (16.6%), the hard palate (16.6%), the floor of the mouth (16.

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