Dermatologic Manifestations of Verrucous Carcinoma Treatment & Management

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

Surgical Care

Most physicians treat patients with cutaneous verrucous carcinoma (VC) in their offices. Complete tumor extirpation should be performed at first presentation because verrucous carcinoma can recur, metastasize, and, ultimately, cause death. Recurrent verrucous carcinoma carries a relatively poor prognosis.

Surgical excision and Mohs micrographic (MMS) surgery represent the treatments of choice for cutaneous verrucous carcinomas.[31]

Excision with conventional margins [32]

Simple excision is most valuable in the treatment of small verrucous carcinomas of the trunk and extremities and in areas in which tissue sparing is not essential.

Cure rates following simple excision of well-defined T1 lesions can be as high as 95-99%.

A 4-mm margin of healthy tissue is recommended for straightforward lesions.

Standard excision with permanent conventional sections is a highly effective treatment for many verrucous carcinomas. The depth of the excision should include the subcutaneous fat because even small verrucous carcinomas may extend into the subcutaneous fat.

The disadvantages of excision with an arbitrary margin are that in some cases, the pathology reveals a subclinical positive margin, requiring further surgery. In extensive tumors with inflammatory changes, the surgical margin may be difficult to define. Additionally, more healthy tissue may be excised than is necessary.[8]

Mohs surgery [33, 34, 35]

A dermatologic surgeon usually offers MMS. The main advantage of MMS over simple excision in the extirpation of cutaneous verrucous carcinoma is the ability to examine all excision margins (deep and lateral) and to carefully map residual foci of invasive carcinoma.

MMS provides a cure rate for verrucous carcinoma of 94-100% and has been of particular value in curing verrucous carcinoma with perineural invasion. MMS offers the added benefit of preserving normal tissue, thus facilitating reconstruction.

MMS is performed routinely in an outpatient setting with the patient under local anesthesia.

MMS is not widely available outside the United States.

A multidisciplinary approach using MMS performed in conjunction with a plastic surgeon, otolaryngologist, and radiation oncologist may allow for the complete removal of deeply invasive verrucous carcinoma, preservation of vital structures, and facilitation of the reconstruction of a large operative defect.

Because of its many advantages, MMS is the procedure of choice for verrucous carcinoma for which tissue preservation is needed. Furthermore, surgery for verrucous carcinoma using MMS may be an integral component in the management of certain verrucous carcinomas that otherwise would be beyond the experience of the cutaneous surgeon.

Cryosurgery [36]

Cryosurgery using liquid nitrogen is a safe and low-cost procedure for the ablation of selected verrucous carcinomas and is well tolerated by patients.

Cryotherapy has provided a high cure rate for select well-circumscribed superficial verrucous carcinomas. Because of no histologic control, close follow-up is necessary.

This procedure is the least likely to result in cure and is the least preferred intervention.

Curettage and electrodesiccation

Cure rates of 96-99% have been quoted in several large studies for destruction of T0 and T1 verrucous carcinoma (ie, in situ lesions and invasive lesions < 2 cm in diameter). This high cure rate was affected by careful patient selection.

The main disadvantage of curettage and electrodesiccation is a lack of margin control; nonetheless, the procedure is minimally invasive, well tolerated, and effective for in situ lesions without deep involvement.

Curettage and electrodesiccation is most appropriate for slow-growing lesions of the trunk and extremities.

Radiation therapy [37, 38, 39]

Radiation therapy offers the potential advantage of avoiding the trauma and deformity of a surgical procedure, but it has occasionally been associated with transformation to high-grade squamous carcinoma.

Ionizing radiation therapy is used mainly as a treatment for primary cutaneous carcinoma in patients who cannot tolerate surgery (eg, elderly patients).

Cure rates for T1 lesions range from 85-95%.

Although the initial cosmetic result following radiation often is good, the long-term result frequently is poor, with atrophy, hypopigmentation, and telangiectasia. Some patients treated with radiation also develop radiation necrosis. This risk increases over time.

Radiation therapy is not advocated for use over bony structures because of the risk of osteoradionecrosis. Radiation therapy is not advocated for patients who are young or of middle aged.

Radiation therapy is expensive and requires multiple visits. The procedure is blind to histologic margin control. For these reasons, the use of radiation as primary therapy for verrucous carcinoma generally is restricted to older patients who cannot tolerate or who refuse surgery.

Other considerations

Other treatments that have been used for cutaneous verrucous carcinomas with variable success include topical or systemic chemotherapy (bleomycin, 5-fluorouracil, cisplatin, methotrexate), carbon-dioxide laser, intralesional interferon alfa, imiquimod, and photodynamic therapy.[40]

In oral verrucous carcinoma in the presence of clinical lymphadenopathy and if the pathological diagnosis is uncertain, neck treatment should be considered.[8]

If bone involvement is suspected, radiography or computed tomography scanning should be performed.

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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.

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.

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