Verrucous Carcinoma Clinical Presentation

Updated: Dec 17, 2017
  • Author: Jennifer Shuley Ruth, MD; Chief Editor: William D James, MD  more...
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Presentation

History

Verrucous carcinoma manifests as a cauliflowerlike, exophytic mass that typically develops at sites of chronic irritation and inflammation. Verrucous carcinoma is slow growing, but may display locally aggressive behavior. Penetration into the skin, fascia, and even bone has been reported; however, verrucous carcinoma has low metastatic potential. [15]

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Physical Examination

Verrucous carcinoma may affect any part of the skin or mucosa, but it most commonly involves the oral cavity, anogenital region, or sole of the foot. Thus, it has been grouped into four clinicopathologic types based on the affected anatomic site: oroaerodigestive, anogenital, feet, and other cutaneous sites. [7, 16] However, this classification and the associated naming scheme is not used consistently across the literature, leading to confusing and, often, overlapping, nomenclature. Based on the anatomic site of involvement, verrucous carcinoma may be classified as described below.

Oroaerodigestive verrucous carcinoma  (Ackerman tumor, oral florid papillomatosis [17] )

The oral cavity is the most common site of occurrence of verrucous carcinoma and represents 2-12% of all oral carcinomas. [13, 18, 19, 20, 21]

Early lesions appear as white, translucent patches on an erythematous base. They may develop in previous areas of leukoplakia, lichen planus, [22, 23] 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 local invasion into soft tissues and bone (eg, mandible) may occur.

Oroaerodigestive verrucous carcinoma most commonly occurs on the buccal mucosa. [13] Other sites of oral involvement are the alveolar ridge, upper and lower gingiva, floor of the mouth, tongue, tonsils, and vermilion border of the lip. [24] Verrucous carcinoma involving the hard palate and upper alveolus is considered more aggressive. [13]

The larynx may also be affected; it usually presents as a bulky exophytic lesion with a papillomatous appearance that projects from the larynx. [25, 26] Furthermore, sinonasal tract involvement has also rarely been reported. [27, 28]

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.

Anogenital 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. [29]  The tumor accounts for 5-16% of all penile carcinomas. [30]

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. [29, 31]

The Buschke-Löwenstein tumor is preferentially seen in men and immunocompromised patients. [29] It commonly occurs on the glans penis, mainly in uncircumcised men. In females, this tumor is most often found on the vulva. [32, 33]

Less commonly, the Buschke-Löwenstein tumor occurs in the bladder [6, 34] or on vaginal, cervical, perianal, scrotal, and pelvic organs.

Verrucous carcinoma of the foot  (epithelioma cuniculatum) [7, 35, 36]

Verrucous carcinoma of the skin is typically a long-standing, slow-growing tumor that is usually found at the sole of the foot and, less frequently, the toes or heels. [37]

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

Lesions can often be misdiagnosed for plantar warts that grow slowly into a large exophytic mass. [36]

Verrucous carcinoma of the foot most often occurs as a single mass or plaque, but multiple verrucous carcinomas on the feet and ankles have been reported. [37]

Verrucous carcinoma of the foot is considered to have a very low incidence of metastases. Nevertheless, in long-standing tumors, underlying structures such as the bone, cartilage, and tendons can be involved. [36]

Other cutaneous sites  (cutaneous verrucous carcinoma) [4, 7, 36]

Verrucous carcinomas arising from other cutaneous sites beyond the foot (eg, scalp, face, nail apparatus, arm) have also been reported. [38, 36, 39, 40]

These tumors, like their counterparts encountered on the sole of the foot, tend to present as slowly enlarging, locally aggressive, exophytic masses with low metastatic potential.

Cutaneous verrucous carcinoma has been reported to develop at sites of inflammation or scarring such as decubitus ulcers, gunshot wounds, burn scars, lupus vulgaris scars, and areas affected by hidradenitis suppurativa. [7, 11]

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