Verrucous Carcinoma Workup

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



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.



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