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Verrucous Carcinoma
4 Interesting facts of Verrucous Carcinoma
- A high degree of suspicion is required for large verrucous and/or papillomatous lesions that manifest aggressive behavior, particularly in the oral cavity, on anogenital area, or on acral skin.
- The diagnosis is established via deep incisional biopsy. The examining pathologist should be told of the clinical concern for verrucous carcinoma. A superficial sample (shave) or small sample (punch) is usually not diagnostic because the examiner needs to be able to evaluate the growth pattern. HPV subtyping may be helpful.
- Complete surgical extirpation is the treatment of choice for verrucous carcinoma. Because of the typical large size, the surgery may be difficult. Local recurrence rates are high, perhaps over 50% in some studies. Micrographic surgery (Mohs surgery) should be considered, if this technique is available.
- The clinical course is that of a locally aggressive malignancy, with considerable morbidity and lesser mortality. Published recurrence rates in the literature vary, but in some studies the local recurrence rate has exceeded 50%. The tumor only rarely becomes metastatic, but, in some studies, about 20% to 30% of patients eventually died from complications of the malignancy.
Etiology and Risk Factors
What causes this condition?
- Verrucous carcinoma is a variant of well-differentiated squamous cell carcinoma that most often occurs in the oral cavity (Ackerman tumor), on the genitalia (Buschke-Löwenstein tumor), and on acral skin, particularly the foot (epithelioma cuniculatum). Cases of verrucous carcinoma often arise in long-standing warts. Molecular studies have identified HPV in the tumor, with subtypes 1, 2, 11, 16, and 18 being most common. Other cases have arisen in areas of chronic trauma or inflammation, such as scars, chronic draining fistulas, dystrophic epidermolysis bullosa, and lupus vulgaris (cutaneous tuberculosis).
- Verrucous carcinoma is more common in older patients, with the only exception being cases that arise in dystrophic epidermolysis bullosa.
Diagnosis
Approach to Diagnosis
- A high degree of suspicion is required for large verrucous and/or papillomatous lesions that manifest aggressive behavior, particularly in the oral cavity, on anogenital area, or on acral skin.
Workup
Physical Examination
- Lesions are typically slow-growing and are composed of hyperkeratotic papillomatous or verrucous plaques or tumors of variable size.
- The tumor may contain crypts of keratin that can lead to draining abscesses and fistulas.
How is this condition diagnosed?
Diagnostic Procedures
- The diagnosis is established via deep incisional biopsy. The examining pathologist should be told of the clinical concern for verrucous carcinoma. A superficial sample (shave) or small sample (punch) is usually not diagnostic because the examiner needs to be able to evaluate the growth pattern. HPV subtyping may be helpful.
- Verrucous carcinoma can be a difficult histologic diagnosis to make. If a first sampling results in a benign diagnosis, such as pseudoepitheliomatous hyperplasia, but if clinical concern for verrucous carcinoma persists at the site, a larger second biopsy should be performed, and/or the case should be discussed with the pathologist or dermatopathologist.
How is Verrucous Carcinoma treated?
Treatment Procedures
- Complete surgical extirpation is the treatment of choice for verrucous carcinoma. Because of the typical large size, the surgery may be difficult. Local recurrence rates are high, perhaps over 50% in some studies. Micrographic surgery (Mohs surgery) should be considered, if this technique is available.
- LN2 cryosurgery might be considered for lesions that cannot be resected, but this destructive modality does not allow for margin control, and it must be performed by someone with expertise in this area.
- Radiation therapy can also be performed in cases that are inoperable, but, on occasion, this treatment can transform the tumor into a higher-grade form of squamous cell carcinoma.
References
1.Ahsaini M, Tahiri Y, Tazi MF, et al. Verrucous carcinoma arising in an extended giant condyloma acuminatum (Buschke-Löwenstein tumor): a case report and review of the literature. Journal of medical case reports. 2013;7:1-5.
2.Penera KE, Manji KA, Craig AB, Grootegoed RA, Leaming TR, Wirth GA. Atypical presentation of verrucous carcinoma: a case study and review of the literature. Foot & ankle specialist. 2013;6(4):318-322.
