eMedicine Specialties > Dermatology > Malignant Neoplasms

Verrucous Carcinoma

Author: Bassam Zeina, MD, PhD, Consulting Staff, Department of Dermatology, Milton Keynes Hospital, UK
Coauthor(s): Nicole Sakka, MBBS, Foundation Year 2, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK; Sohail Mansoor, MBBS, MSc, Dermatologist and Lead Physician in Dermatologic Surgery, Department of Dermatology, Barnet Hospital, UK
Contributor Information and Disclosures

Updated: Jul 9, 2009

Introduction

Background

Verrucous carcinoma (VC) refers to a clinicopathologic concept implying a locally aggressive, clinically exophytic, low-grade, slow-growing, well-differentiated squamous cell carcinoma with minimal metastatic potential.

Verrucous carcinoma typically involves the oral cavity, larynx, genitalia, skin, and esophagus.

In 1948, Ackerman first described verrucous carcinoma in the oral cavity as a low-grade tumor that generally is considered a clinicopathologic variant of squamous cell carcinoma.1 Aird et al first described cutaneous verrucous carcinoma (carcinoma cuniculatum) in 1954.2

Pathophysiology

The pathogenesis of verrucous carcinoma is not yet fully elucidated. Leading theories include human papillomavirus (HPV) infection (anogenital and some oral and sole lesions),3 chemical carcinogenesis induced by smoking and chewing tobacco,4 alcohol consumption and betel nut chewing (oral lesions), and chronic inflammation. Schistosomiasis is associated with verrucous carcinoma of the bladder.

Frequency

The incidence of verrucous carcinoma in the United States and worldwide is unknown.

Mortality/Morbidity

Overall, patients with verrucous carcinoma have a favorable prognosis, although the course of verrucous carcinoma lesions is characterized by slow, continuous, local growth. Morbidity results from local skin and soft tissue destruction and, occasionally, from perineural, muscle, and even bone invasion. The development of distant metastases is rare. Verrucous carcinoma mortality usually is due to local invasion rather than metastatic spread.

Race

Verrucous carcinoma is reported predominantly in whites.

Sex

Verrucous carcinoma primarily affects men.

Age

Verrucous carcinoma generally occurs in patients aged 55-65 years; however, the anogenital type of verrucous carcinoma has been reported to develop in men aged 18-86 years.

Clinical

History

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 penetrate deeply into the skin, fascia, and even bone.5

Physical

Verrucous carcinoma typically involves the oral cavity, larynx, genitalia, skin, and esophagus. Based on the different sites of occurrence, verrucous carcinomas are categorized as follows:

  • Oral verrucous carcinoma (Ackerman tumor, oral florid papillomatosis6 )
    • The oral cavity is the most common site of occurrence of verrucous carcinoma.7
    • Early lesions appear as white, translucent patches on an erythematous base. They may develop in previous areas of leukoplakia, lichen planus,8,9 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.7 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.7
    • In these patients, the majority of the tumors present at advanced stages (III-IV).7
  • 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.10
    • 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.10
    • The Buschke-Löwenstein tumor is preferentially seen in men and immunocompromised patients.10 It commonly occurs on the glans penis, mainly in uncircumcised men.
    • Less commonly, the Buschke-Löwenstein tumor occurs in the bladder11,12 or on vaginal, cervical, perianal, scrotal, vulvar, and pelvic organs.
  • Palmoplantar verrucous carcinoma (epithelioma cuniculatum)13,14,15,16,17
    • Most cutaneous verrucous carcinomas are found on the plantar surface of the foot. These tumors most commonly involve the skin overlying the first metatarsal head, but they also occur on the toes, heel, medioplantar region, dorsum, and amputated stumps.18
    • Cutaneous verrucous carcinomas have been reported to develop at sites at long-standing cutaneous scars, including gunshot wounds and burn scars.18
    • Lesions are usually slow growing, exophytic, and locally invasive, and they can be misdiagnosed for verruca vulgaris.18
    • Exophytic tumors with ulceration and sinuses draining foul-smelling discharge cause pain, bleeding, and difficulty walking.
    • Palmoplantar verrucous carcinoma is consider to have a very low incidence of metastases.18
    • Cutaneous verrucous carcinoma often occurs as a single mass or plaque, but multiple verrucous carcinomas on the feet and ankles have been reported.19
    • Verrucous carcinomas arising from other sites (eg, trunk, extremities, scalp, face) also have been reported.
  • Others
    • Laryngeal verrucous carcinoma usually occurs as a bulky exophytic lesion with a papillomatous appearance that projects from the larynx.20
    • Verrucous carcinomas of the endometrium21 and the sinonasal track have been reported.22 Verrucous carcinomas may develop in areas of previous hidradenitis suppurativa23 and genital lichen sclerosus.24

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.25,26 HPV types 6 and 11 are found in the Buschke-Löwenstein tumor.10
  • Chronic inflammation may lead to the development of verrucous carcinoma. Inflammatory diseases (eg, long-standing oral ulcerative lichen planus) seem to predispose patients to the development of verrucous carcinoma.
  • Associations with verrucous carcinoma have been found in patients who chewed tobacco and betel nuts, dipped snuff, and/or consumed alcohol. Lesions developed at the sites where tobacco was habitually placed in the mouth.7
  • 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.7

More on Verrucous Carcinoma

Overview: Verrucous Carcinoma
Differential Diagnoses & Workup: Verrucous Carcinoma
Treatment & Medication: Verrucous Carcinoma
Follow-up: Verrucous Carcinoma
References
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Further Reading

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Keywords

verrucous carcinoma, verrucous cell carcinoma, Ackerman tumor, Ackerman's tumor, Buschke-Loewenstein tumor, florid oral papillomatosis, carcinoma cuniculatum, warty cancer, epithelioma cuniculatum, squamous cell carcinoma de novo, VC

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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.

Medical Editor

Kelly M Cordoro, MD, Assistant Professor, Pediatric and Adult Dermatology, Department of Dermatology, University of California at San Francisco
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.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University 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.

Managing Editor

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.

CME Editor

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

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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