Verrucous Carcinoma Treatment & Management

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

Surgical Care

Most physicians treat patients with cutaneous verrucous carcinoma in their offices. Complete tumor removal should be performed expeditiously because verrucous carcinoma can recur, metastasize, and, ultimately, cause death. [42] Recurrent verrucous carcinoma carries a relatively poor prognosis.

Surgical excision and Mohs micrographic (MMS) surgery represent the treatments of choice for cutaneous verrucous carcinomas. [43, 44]

Surgical excision  [45]

Complete surgical resection with clear margins is recommended once the diagnosis of verrucous carcinoma has been established.

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. Furthermore, incomplete surgical resection can lead to acceleration in the growth of the tumor. Finally, as opposed to tissue-sparing modalities, more healthy tissue may be excised than is necessary. [13]

Mohs surgery  [46, 47, 48]

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 allows for tissue preservation, thus facilitating reconstruction; this can be of particular benefit in sensitive areas of the body such as the anogenital region where preservation of sexual function and body image are of great importance.

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  [49, 50]

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

The major disadvantage of cryosurgery is the lack of histologic control and lack of precision in application of treatment, which often leads to the need for multiple treatments. Initial shave excision of the bulk of the tumor may allow for more direct therapy and thus, a higher cure rate.

This procedure is the least likely to result in cure and, therefore, is not a preferred intervention.

Radiation therapy  [51, 52, 53]

Radiation therapy offers the potential advantage of avoiding the trauma and deformity of a surgical procedure, but it remains a controversial modality, owing to its potential association with transformation to a high-grade squamous carcinoma. Although reported in earlier literature, [54] the association between radiation and anaplastic transformation of verrucous carcinoma appears to be less frequent than previously reported. [55, 56]

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

Long-term cosmetic outcomes can be problematic, and osteonecrosis has been reported. Although controversial, the risk of anaplastic transformation following radiation may weigh into treatment decisions.

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 middle aged.

Radiation therapy is expensive and requires multiple visits. The procedure is blind to histologic margin control and may be linked to anaplastic transformation. 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 curettage and electrodessication, topical or systemic chemotherapy (bleomycin, 5-fluorouracil, cisplatin, methotrexate), carbon dioxide laser, intralesional interferon-alfa, imiquimod, and photodynamic therapy. [57]

Possible medicolegal pitfalls

The main pitfall in the diagnostic evaluation is taking an inadequate biopsy specimen, leading some to advise the use of excisional biopsy whenever the diagnosis of verrucous carcinoma is suspected. [45] Additionally, in some cases, the carcinoma is so well differentiated that the pathologist may read the tissue as pseudoepitheliomatous hyperplasia. Verrucous carcinoma has the potential to cause substantial morbidity and even mortality, and physicians who diagnose and treat verrucous carcinoma are held legally accountable for their actions.

Failure to ensure adequate patient follow-up care is a pitfall because primary treatment of verrucous carcinoma is not a guarantee of cure. Not informing patients of the potential morbidity associated with verrucous carcinoma may lead to the lesion being regarded as trivial and not requiring follow-up care. The courts hold the physician, not the patient, responsible for appropriate follow-up care. Missed appointments for patients with verrucous carcinoma before or following surgery may indicate a worried or angry patient and should be followed up with a phone call to reschedule and, if necessary, with a certified letter.

Failure to outline all possible risks prior to verrucous carcinoma surgery is another pitfall. Surgery for patients with verrucous carcinoma may cause bleeding, infection, scar formation, deformity, and nerve damage. Removal of deeply invasive lesions may lead to substantial morbidity, including pain syndromes and paralysis. If a surgical complication develops, the physician who performed the primary procedure is held legally responsible, regardless of who handles the complication. Any patient with lesions that are outside the realm of comfort of an individual physician should be referred to another physician.

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Long-Term Monitoring

Verrucous carcinoma usually is cured with appropriate therapy. However, recurrence of cutaneous carcinoma with clear surgical margins has been reported. In addition, patients with a history of verrucous carcinoma should be evaluated with regular skin examinations at 3- to 12-month intervals.

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