Verrucous Carcinoma Workup: Imaging Studies, Procedures, Histologic Findings

Sections

Workup

Imaging Studies

Computed tomography or magnetic resonance imaging may be used to demonstrate the exact location and extent of the verrucous carcinoma for preoperative staging and surgical planning.

Procedures

A skin biopsy is always required for definitive diagnosis of verrucous carcinoma, despite the fact that the diagnosis is suspected strongly on clinical grounds.

Biopsy is performed routinely in the physician's office using a local anesthetic.

All skin biopsy specimens obtained to diagnose verrucous carcinoma must reach at least the depth of the mid dermis to allow for determination of the presence or absence of invasive disease.

A deep (scoop) shave biopsy, a punch biopsy, an incisional biopsy, or an excisional biopsy may be performed.

Pathology readings preferably are made by a dermatopathologist who has extensive experience with verrucous carcinoma.

Histologic Findings

Regardless of site of origin, verrucous carcinomas share the same histological features. Verrucous carcinoma of all types may resemble a verruca superficially, with hyperkeratosis, parakeratosis, acanthosis, papillomatosis, and granular cell layer vacuolization. A characteristic feature is the blunt projections of well-differentiated epithelium surrounded by edematous stroma and chronic inflammatory cells that extend into the dermis, sometimes forming sinuses filled with keratin. Cutaneous verrucous carcinomas may be confused with warty carcinomas, but the higher-grade cytological atypia and the more infiltrative growth pattern of warty carcinomas can help to differentiate.

Staging

Although most verrucous carcinomas are nonmetastatic, staging is still based on the tumor, nodes, metastases (TNM) staging system. The specifics of staging vary based on the anatomic site, with slightly different criteria for oral, anal, and penile lesions. No specific staging system exists for cutaneous verrucous carcinoma; however, the seventh edition of the American Joint Committee for Cancer Staging Manual does propose a staging system for cutaneous squamous cell carcinomas and other cutaneous carcinomas, as follows^[41]:

TX lesions - Primary tumor cannot be assessed
T0 lesions - No evidence of primary tumor
Tis - Carcinoma in situ
T1 lesions - Less than 2 cm in diameter with fewer than two high risk features (eg, depth/invasion >2 mm or high-risk anatomic site)
T2 lesions - Greater than 2 cm in diameter or tumor any size with two or more high-risk features
T3 lesions - Tumor with invasion of maxilla, mandible, orbit, or temporal bone
T4 lesions - Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of base of skull

Treatment & Management

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Media Gallery

Verrucous carcinoma; an exophytic and hyperkeratotic mass that discharged malodorous debris through several sinus tracts. Courtesy of J García-Gavín, D González-Vilas, L Rodríguez-Pazos, D Sánchez-Aguilar, and J Toribio, via Wikimedia Commons.

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Author

Jennifer Shuley Ruth, MD Resident Physician, Department of Dermatology, Baylor College of Medicine

Jennifer Shuley Ruth, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for Dermatologic Surgery, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Mohsin R Mir, MD Private Practice, Mohs Micrographic Surgery and Dermatologic Surgery, Kelsey-Seybold Clinic; Assistant Professor, Baylor College of Medicine

Mohsin R Mir, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Texas Medical Association, Association of Military Dermatologists, Texas Dermatological Society

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; Past President, American College of Mohs Surgery

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: QualDerm Partners; Novascan<br/>Have a 5% or greater equity interest in: QualDerm Partners - North Carolina.

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, Society for Investigative Dermatology

Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.

Additional Contributors

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, Medical Society of Virginia, Society for Pediatric Dermatology, Women's Dermatologic Society, Association of Professors of Dermatology, National Psoriasis Foundation, Dermatology Foundation

Disclosure: Nothing to disclose.

Acknowledgements

Mohsin Ali, MBBS, FRCP, MRCP, MRCPI, Consulting Staff, Department of Dermatology, Amersham General Hospital, 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.

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

Disclosure: Nothing to disclose.

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.

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