Verrucous hyperplasia and verrucous carcinoma in head and neck : use and benefit of methotrexate

Background and aim: Verrucous hyperplasia (VH) and verrucous carcinoma (VC) of the head and neck are two (pre)malignant entities that are slowly progressive with low tendency to metastasize. However, they can reduce the patient's Quality of Life (QoL) and may even transform into squamous cell carcinoma (SCC). As they are typically approached by surgical resection, some patients do not qualify for surgery. Methotrexate may be a systemic alternative but the response is mostly not durable. This case report tries to illustrate the potential role of methotrexate in VH/VC of the head and neck. Method: We describe four cases of patients with VH or VC of the head and neck who received methotrexate (40-60 mg/m(2)) in a weekly or two-weekly interval. Results: Two patients received methotrexate in a neoadjuvant setting. The first patient achieved a macroscopical complete response after 16 cycles and remained in remission after surgery. The second patient suffered from residual disease after 26 cycles and refused radical surgery. Two other patients refused surgery at the time of diagnosis and were proposed methotrexate as a salvage treatment. The first patient had an ongoing response on methotrexate after >60 cycles. The second patient achieved macroscopical complete remission after 28 cycles of methotrexate but suffered relapse by developing an oropharyngeal SCC in the same region. Conclusion: When surgery is not desirable in VH and/or VC, patients can be treated with methotrexate which has a reasonable effect and seems to be well tolerated. Nevertheless, surgery should be the preferred strategy to achieve complete remission