Dermatologic Manifestations of Verrucous Carcinoma Clinical Presentation

  • Author: Bassam Zeina, MD, PhD; Chief Editor: William D James, MD   more...
 
Updated: Jan 24, 2012
 

History

Verrucous carcinoma is a slowly growing and locally destructive tumor. The verrucous carcinoma lesion manifests as a verrucous, exophytic, or endophytic mass that typically develops at sites of chronic irritation and inflammation. The verrucous carcinoma tumor enlarges slowly but may be locally destructive and can penetrate deeply into the skin, fascia, and even bone, but it has a low metastatic potential.[6]

Next

Physical

Verrucous carcinoma most commonly involves the oral cavity, larynx, genital area, and soles of the feet. Other areas of involvement are the esophagus, sinonasal track, middle ear, temporal bone, nose, endometrium, and bladder. Based on the different sites of occurrence, verrucous carcinomas are categorized as follows:

Oral verrucous carcinoma  (Ackerman tumor, oral florid papillomatosis[7] )

The oral cavity is the most common site of occurrence of verrucous carcinoma and represents 2-12% of all oral carcinomas.[8, 9]

Early lesions appear as white, translucent patches on an erythematous base. They may develop in previous areas of leukoplakia, lichen planus,[10, 11] chronic lupus erythematosus, cheilitis, candidiasis, or submucous fibrosis.

The more fully developed lesions are white, soft, cauliflowerlike papillomas with a pebbly surface that may extend and coalesce over large areas of the oral mucosa.

Ulceration, fistulation, and invasion locally into soft tissues and bone (eg, mandible) may occur. Oral verrucous carcinoma most commonly occurs on the buccal mucosa.[8] Other sites of involvement are the alveolar ridge, upper and lower gingiva, floor of the mouth, tongue, tonsils, and vermilion border of the lip.

Painful nonmalignant lymphadenopathy can be seen with concurrent infection or inflammation.

Tumors most often grow around the lymph nodes rather than metastasizing to them. If metastases do occur, they usually remain limited to the regional lymph nodes.

Oral verrucous carcinoma involving the hard palate and upper alveolus is considered more aggressive.[8]

In these patients, the majority of the tumors present at advanced stages (III-IV).[8]

Anogenital-type verrucous carcinoma (Buschke-Löwenstein tumor)

The Buschke-Löwenstein tumor usually manifests as an exophytic tumor of the genital or perianal area, with ulceration and sometimes fistulae and sinuses.[12] The tumor accounts for 5-24% of all penile carcinomas.

They typically manifest as large, exophytic, nonhealing, cauliflowerlike lesions with a verrucous or ulcerated surface. The Buschke-Löwenstein tumor usually can only be differentiated from ordinary condylomata based on histologic findings. These tumors tend to infiltrate deeply, and recurrence is common.[12]

The Buschke-Löwenstein tumor is preferentially seen in men and immunocompromised patients.[12] It commonly occurs on the glans penis, mainly in uncircumcised men.

Less commonly, the Buschke-Löwenstein tumor occurs in the bladder[13, 14] or on vaginal, cervical, perianal, scrotal, vulvar, and pelvic organs.

Palmoplantar verrucous carcinoma  (epithelioma cuniculatum)[15, 16, 17, 18, 19] }[20]

Verrucous carcinoma of the skin is typically a long-standing, slow-growing, well-circuited tumor that is usually found at the sole of the foot (53%), toes (21%) and heel (16%). Verrucous carcinomas arising from other sites (eg, trunk, extremities, scalp, face, nail apparatus) have also been reported.[21]

Lesions are usually slow growing, exophytic, and locally invasive. Lesions may exhibit hyperkeratosis, ulceration, and sinuses that may draining foul-smelling discharge and cause pain, bleeding, and difficulty walking.

Lesions can often be misdiagnosed for plantar wards that grow slowly into a large exophytic mass.[22]

Cutaneous verrucous carcinoma most often occurs as a single mass or plaque, but multiple verrucous carcinomas on the feet and ankles have been reported.[21]

Verrucous carcinomas of the skin have been reported to develop at sites of long-standing cutaneous scars, including gunshot wounds and burn scars.[22]

Palmoplantar verrucous carcinoma is consider to have a very low incidence of metastases. Nevertheless, in long-standing tumors, underlying structures such as the bone, cartilage, and the tendons can be involved.[22]

Others

Laryngeal verrucous carcinoma usually occurs as a bulky exophytic lesion with a papillomatous appearance that projects from the larynx.[23, 24]

Verrucous carcinomas of the endometrium[25] and the sinonasal track have been reported.[26] Verrucous carcinomas may develop in areas of previous hidradenitis suppurativa.[27] Genital verrucous carcinoma has been associated with genital lichen sclerosus.[28]

Uncommon areas of involvement such as the orbit, middle ear, temporal bone, nose, nasopharynx, and paranasal sinuses, have been reported.

Previous
Next

Causes

HPV infection is thought to facilitate or cause verrucous carcinoma. HPV infection is believed to play the predominate role in the development of verrucous carcinoma of the penis, vulva, and periungual region. HPV-16 has been identified frequently in genital and periungual verrucous carcinoma.[29, 30]

HPV types 6 and 11 are found in the Buschke-Löwenstein tumor up to 50% of the time.[12] In oral verrucous carcinomas, HPV types 6, 11, 16, and 18 have been found.[8] In plantar lesions, HPV types 11 and 16 have been associated.[20]

Inflammatory diseases such as long-standing oral ulcerative lichen planus and chronic candidiasis seem to predispose patients to the development of verrucous carcinoma.

Associations in oral verrucous carcinoma have been found in patients who chewed or inhaled tobacco and betel nuts, dipped snuff, and/or consumed alcohol. Lesions developed at the sites where tobacco was habitually placed in the mouth.[8]

Schistosomal infection often is coexistent with verrucous carcinoma of the bladder.

Oral verrucous carcinoma is associated with poor dental hygiene, ill-fitting dentures, and low socioeconomic status. Oral verrucous carcinoma has a higher incidence in males and in immunocompromised patients.[8]

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Bassam Zeina, MD, PhD  Consulting Staff, Department of Dermatology, Milton Keynes Hospital, UK

Bassam Zeina, MD, PhD is a member of the following medical societies: British Association of Dermatologists, British Medical Association, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nicole Sakka, MBBS  Foundation Year 2, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK

Disclosure: Nothing to disclose.

Sohail Mansoor, MBBS, MSc  Dermatologist and Lead Physician in Dermatologic Surgery, Department of Dermatology, Barnet Hospital, UK

Sohail Mansoor, MBBS, MSc is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Dermatology, American Society for Dermatologic Surgery, Royal College of Physicians and Surgeons of Glasgow, and Royal College of Physicians of the United Kingdom

Disclosure: Nothing to disclose.

Specialty Editor Board

Kelly M Cordoro, MD  Assistant Professor of Clinical Dermatology and Pediatrics, Department of Dermatology, University of California, San Francisco School of Medicine

Kelly M Cordoro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Association of Professors of Dermatology, Dermatology Foundation, Medical Society of Virginia, National Psoriasis Foundation, Society for Pediatric Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Richard P Vinson, MD  Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA

Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association

Disclosure: Nothing to disclose.

John G Albertini, MD  Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Program Director, ACGME Accredited Fellowship in Procedural Dermatology

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD  Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Mohsin Ali, MBBS, FRCP, MRCP, to the development and writing of this article.

References

  1. Ackerman LV. Verrucous carcinoma of the oral cavity. Surgery. Apr 1948;23(4):670-8. [Medline].

  2. Aird I, Johnson HD, Lennox B, Stansfeld AG. Epithelioma cuniculatum: a variety of squamous carcinoma peculiar to the foot. Br J Surg. Nov 1954;42(173):245-50. [Medline].

  3. Aroni K, Lazaris AC, Ioakim-Liossi A, Paraskevakou H, Davaris PS. Histological diagnosis of cutaneous "warty" carcinoma on a pre-existing HPV lesion. Acta Derm Venereol. Jul-Aug 2000;80(4):294-6. [Medline].

  4. Mirbod SM, Ahing SI. Tobacco-associated lesions of the oral cavity: Part II. Malignant lesions. J Can Dent Assoc. Jun 2000;66(6):308-11. [Medline].

  5. Terada T. Verrucous carcinoma of the skin: a report on 5 Japanese cases. Ann Diagn Pathol. Jun 2011;15(3):175-80. [Medline].

  6. Hagiwara H, Kanazawa T, Ishikawa K, et al. Invasive verrucous carcinoma: a temporal bone histopathology report. Auris Nasus Larynx. Apr 2000;27(2):179-83. [Medline].

  7. Grinspan D, Abulafia J. Oral florid papillomatosis (verrucous carcinoma). Int J Dermatol. Oct 1979;18(8):608-22. [Medline].

  8. Walvekar RR, Chaukar DA, Deshpande MS, et al. Verrucous carcinoma of the oral cavity: A clinical and pathological study of 101 cases. Oral Oncol. Jan 2009;45(1):47-51. [Medline].

  9. Depprich RA, Handschel JG, Fritzemeier CU, Engers R, Kubler NR. Hybrid verrucous carcinoma of the oral cavity: A challenge for the clinician and the pathologist. Oral Oncology EXTRA. 2006;42:85-90.

  10. Castano E, Lopez-Rios F, Alvarez-Fernandez JG, Rodriguez-Peralto JL, Iglesias L. Verrucous carcinoma in association with hypertrophic lichen planus. Clin Exp Dermatol. Jan 1997;22(1):23-5. [Medline].

  11. Warshaw EM, Templeton SF, Washington CV. Verrucous carcinoma occurring in a lesion of oral lichen planus. Cutis. Apr 2000;65(4):219-22. [Medline].

  12. Levy A, Lebbe C. [Buschke-Löwenstein tumour: diagnosis and treatment]. Ann Urol (Paris). Jun 2006;40(3):175-8. [Medline].

  13. Blackmore CC, Ratcliffe NR, Harris RD. Verrucous carcinoma of the bladder. Abdom Imaging. Sep-Oct 1995;20(5):480-2. [Medline].

  14. Groeneveld AE. Verrucous carcinoma of the bladder. Br J Urol. Jul 1992;70(1):96-7. [Medline].

  15. D'Aniello C, Grimaldi L, Meschino N, Brandi C, Andreassi A, Bosi B. Verrucous 'cuniculatum' carcinoma of the sacral region. Br J Dermatol. Aug 2000;143(2):459-60. [Medline].

  16. Gallo A, Fiorella ML, Simonelli M, Rocca CD, de Vincentiis M. Carcinoma cuniculatum: verrucous carcinoma of the skin of the face. Otolaryngol Head Neck Surg. Oct 2005;133(4):640. [Medline].

  17. Ho J, Diven DG, Butler PJ, Tyring SK. An ulcerating verrucous plaque on the foot. Verrucous carcinoma (epithelioma cuniculatum). Arch Dermatol. Apr 2000;136(4):547-8, 550-1. [Medline].

  18. Kao GF, Graham JH, Helwig EB. Carcinoma cuniculatum (verrucous carcinoma of the skin): a clinicopathologic study of 46 cases with ultrastructural observations. Cancer. Jun 1 1982;49(11):2395-403. [Medline].

  19. Kempe SA, Kreiser DZ. Epithelioma cuniculatum of the foot. Literature survey and case history. J Am Podiatry Assoc. Jul 1984;74(7):351-4. [Medline].

  20. Pattee SF, Bordeaux J, Mahalingam M, Nitzan YB, Maloney ME. Verrucous carcinoma of the scalp. J Am Acad Dermatol. Mar 2007;56(3):506-7. [Medline].

  21. Kuan YZ, Hsu HC, Kuo TT, Huang YH, Ho HC. Multiple verrucous carcinomas treated with acitretin. J Am Acad Dermatol. Feb 2007;56(2 Suppl):S29-32. [Medline].

  22. Vandeweyer E, Sales F, Deraemaecker R. Cutaneous verrucous carcinoma. Br J Plast Surg. Mar 2001;54(2):168-70. [Medline].

  23. Huang SH, Lockwood G, Irish J, et al. Truths and myths about radiotherapy for verrucous carcinoma of larynx. Int J Radiat Oncol Biol Phys. Mar 15 2009;73(4):1110-5. [Medline].

  24. Witt RL, Wilson P. Missed opportunity for larynx preservation? Failure to distinguish verrucous and squamous cell carcinoma on microlaryngoscopy and biopsy. J Voice. Jan 2009;23(1):140-2. [Medline].

  25. Shidara Y, Karube A, Watanabe M, et al. A case report: verrucous carcinoma of the endometrium--the difficulty of diagnosis, and a review of the literature. J Obstet Gynaecol Res. Jun 2000;26(3):189-92. [Medline].

  26. Shiomori T, Udaka T, Nagatani G, et al. Association of verrucous carcinoma and inverted papilloma in the sinonasal tract. Auris Nasus Larynx. Jun 2007;34(2):281-5. [Medline].

  27. Cosman BC, O'Grady TC, Pekarske S. Verrucous carcinoma arising in hidradenitis suppurativa. Int J Colorectal Dis. Nov 2000;15(5-6):342-6. [Medline].

  28. Nasca MR, Innocenzi D, Micali G. Penile cancer among patients with genital lichen sclerosus. J Am Acad Dermatol. Dec 1999;41(6):911-4. [Medline].

  29. Masih AS, Stoler MH, Farrow GM, Wooldridge TN, Johansson SL. Penile verrucous carcinoma: a clinicopathologic, human papillomavirus typing and flow cytometric analysis. Mod Pathol. Jan 1992;5(1):48-55. [Medline].

  30. Miyamoto T, Sasaoka R, Hagari Y, Mihara M. Association of cutaneous verrucous carcinoma with human papillomavirus type 16. Br J Dermatol. Jan 1999;140(1):168-9. [Medline].

  31. Abbas MA. Wide local excision for Buschke-Löwenstein tumor or circumferential carcinoma in situ. Tech Coloproctol. Sep 2011;15(3):313-8. [Medline].

  32. Yeh CJ. Treatment of verrucous hyperplasia and verrucous carcinoma by shave excision and simple cryosurgery. Int J Oral Maxillofac Surg. Jun 2003;32(3):280-3. [Medline].

  33. Alkalay R, Alcalay J, Shiri J. Plantar verrucous carcinoma treated with Mohs micrographic surgery: a case report and literature review. J Drugs Dermatol. Jan 2006;5(1):68-73. [Medline].

  34. Muro Vidaurre I, Hernaez Manrique I, Sanz Jaka JP, Rekarte Barriola JA, Lluch Costa A. [Verrucous carcinoma of the penis: local excision with the Mohs micrographic technique]. Arch Esp Urol. Nov 1996;49(9):959-64. [Medline].

  35. Padilla RS, Bailin PL, Howard WR, Dinner MI. Verrucous carcinoma of the skin and its management by Mohs' surgery. Plast Reconstr Surg. Mar 1984;73(3):442-7. [Medline].

  36. Ishida CE, Ramos-e-Silva M. Cryosurgery in oral lesions. Int J Dermatol. Apr 1998;37(4):283-5. [Medline].

  37. Ferlito A, Rinaldo A, Mannara GM. Is primary radiotherapy an appropriate option for the treatment of verrucous carcinoma of the head and neck?. J Laryngol Otol. Feb 1998;112(2):132-9. [Medline].

  38. Foroudi F, Turner S. Verrucous scrotal carcinoma: a radioresponsive tumor. J Urol. Nov 1999;162(5):1694-5. [Medline].

  39. Schwade JG, Wara WM, Dedo HH, Phillips TL. Radiotherapy for verrucous carcinoma. Radiology. Sep 1976;120(3):677-9. [Medline].

  40. Nikkels AF, Thirion L, Quatresooz P, Piérard GE. Photodynamic therapy for cutaneous verrucous carcinoma. J Am Acad Dermatol. Sep 2007;57(3):516-9. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.