Microscopically controlled surgery (Mohs' chemosurgery) for treatment of verrucous squamous cell carcinoma of the foot (epithelioma cuniculatum)

Mohs micrographic surgery for verrucous carcinoma: a review of the literature

Verrucous carcinoma is a rare, low grade variant of squamous cell carcinoma that rarely metastasizes but tends to display aggressive local behavior. Wide local excision is the most common treatment, but has high rates of local recurrence, ranging from 19 to 75% in the literature. The cases of verrucous carcinoma treated with Mohs micrographic surgery in the literature, as well as a previously unpublished case is summarized. PubMed was searched for terms related to verrucous carcinoma and Mohs micrographic surgery, and articles reporting cases of verrucous carcinoma treated with Mohs were reviewed and summarized. A previously unpublished case treated at our institution was also reported. Thirty-eight cases of verrucous carcinoma treated with Mohs surgery were analyzed. The average age of patients was 52.1, and 50% were male. The most common sites were the foot (47%) and the anogenital region (34%). Lesion duration ranged from 0.17 to 40 years with a mean of 4.8 years, and tumor diameter ranged from 1 to 10 cm with a mean of 4.6 cm. The local recurrence rate following Mohs was 16%, with nodal metastasis occurring in 3% and no cases of distant metastasis. As verrucous carcinoma demonstrates locally aggressive behavior and a high risk of local recurrence, Mohs micrographic surgery should be considered as first line treatment. Further research directly comparing wide local excision to Mohs surgery is needed.

Cutaneous Verrucous Carcinomas: A Review

Verrucous carcinoma (VC) is a relatively rare locally aggressive, slow-growing, well-differentiated squamous cell carcinoma with minimal metastatic potential and is most frequent in the mucosa. Although rarely reported on the skin, cutaneous verrucous carcinomas (CVC) can appear anywhere, most commonly on the feet. However, clinical and pathologic diagnosis of CVC has been confusing and challenging. It can easily be mistaken for benign or more malignant conditions such as giant condyloma acuminata, keratoacanthoma, and pseudoepithelioma-like hyperplasia or squamous cell carcinoma, resulting in inappropriate management. In this review, we describe the different aspects associated with CVC, including its pathogenesis and clinicopathologic features. The available evidence for the differential diagnosis and treatment of CVC is discussed, and specific management recommendations are made. After the treatment, careful follow-up examinations of the excised area should be performed at regular intervals.

Surgical treatment of verrucous carcinoma: a review

BACKGROUND

Verrucous carcinoma is a rare mucocutaneous malignancy characterized by slow, relentless growth and a low metastasis rate.

OBJECTIVE

Herein we summarize surgical success rates and review newer approaches to the treatment of verrucous carcinomas.Methods & Materials: PubMed electronic searches were performed by B.F. and C.V. using combinations of the following terms: ''verrucous carcinoma,'' ''Ackerman tumor,'' ''Buschke Lowenstein,'' ''epithelioma cuniculatum,'' ''carcinoma cuniculatum,'' ''papillomatosis cutis,'' ''treatment,'' ''therapeutics,'' ''management,'' ''mohs surgery,'' and ''excision.'' A systematic review was conducted on 49 articles in accordance with PRISMA guidelines.

RESULTS

Surgical management remains first-line therapy. Wide local excision is most commonly utilized, with highly variable margins (0.5-3.0 cm) and recurrence rates (4.6-75.0%). Mohs Micrographic Surgery has also been used, especially for recurrent tumors, with an overall recurrence rate of 12.9%.

CONCLUSION

Surgery is the treatment of choice, either by Mohs Micrographic Surgery or wide local excision. However, surgical recurrence rates are high, and tissue-sparing therapies are desirable given the sensitive locations involved. Ultimately, randomized control trials are needed to develop evidence-based guidelines for the management of VCs.

Extensive carcinoma cuniculatum of the mandible

Carcinoma cuniculatum (CC) is a rare variant of squamous cell carcinoma first described in 1954. Cases of CC in the head and neck are exceedingly rare, with 66 cases reported since 1977. These tumors are generally low-grade, well-differentiated and locally aggressive malignancies. Patients are often subjected to a long period of misdiagnoses given the clinical similarity of these entities to odontogenic cysts and abscesses. We report a case of a carcinoma cuniculatum of the mandible with very advanced local involvement of disease, highlighting the unusual characteristics of this rare tumor that are important for clinicians to recognize. Clinical presentation, histology, risk factors, treatment options, and prognosis are also reviewed.

Atypical presentation of verrucous carcinoma: a case study and review of the literature

Verrucous carcinoma is a slow-growing lesion that is most often found on the weight-bearing surface of the foot and should be considered in the differential diagnosis for chronic nonhealing wounds in the diabetic neuropathic population. Accurate diagnosis may be difficult initially and often requires repeat histopathologic evaluation by an experienced pathologist. Verrucous carcinoma can invade deeper tissues; however, extension to bone is a rare occurrence. The authors present a case report of an atypical verrucous carcinoma on the dorsal aspect of the foot and a review of the literature. Studies suggest that multiple therapies exist and recurrence does occur; however, this is less likely with wide excision and more so with Mohs' surgery. With a high clinical suspicion and thorough histopathologic exam, bone involvement and amputation may be avoided.

LEVELS OF EVIDENCE

Therapeutic, Level IV.

AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery

The appropriate use criteria process synthesizes evidence-based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California-Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.

Squamous cell carcinoma of the foot mimicking osteomyelitis: a case report

Bone invasion by squamous cell carcinoma (SCC), other than the regions of the head and neck, is very rare. To our knowledge, and following a search of the National Library of Medicine's Medline database via PubMed, such invasion involving the foot in the absence of osteomyelitis has not been reported. In this case report, we present a rare case of a patient with an ulcerative lesion overlying a SCC in the plantar foot that clinically and radiographically mimicked osteomyelitis of the third digit and third metatarsal. This type of tumor, often referred to as verrucous carcinoma, is characterized by its locally aggressive nature, low potential for metastasis, and well-differentiated nature of SCC. The initial surgical approach consisted of wide excision of the malignant neoplasm, along with partial third ray resection. After pathologic evaluation, which confirmed incomplete excision of the malignancy and absence of osteomyelitis, subsequent surgical intervention was required. Lisfranc's disarticulation/amputation was recommended, not only to ensure removal of any questionable remnants of the SCC, but also to provide a functional limb for ambulation. Although the incidence of SCC is relatively common, the disease process is often under recognized, and podiatrists should consider such malignancy in the presence of chronic ulcerative foot lesions.

Management of verrucous carcinoma of the hand: a case report

BACKGROUND

Verrucous carcinoma is a well-differentiated variant of squamous cell carcinoma seen on mucosa and skin, including the hands.

METHODS

We report the case of a large verrucous carcinoma of the right palm which was completely resected with a fourth ray resection and remained without evidence of tumor recurrence or metastatic disease during follow-up for 11 years. On this basis, we reviewed all 15 previously published cases of verrucous carcinoma of the hand to define the peculiarities of this uncommon tumor and to give diagnostic and therapeutic recommendations.

RESULTS

Verrucous carcinoma is defined by its characteristic clinical presentation as slowly but relentlessly enlarging "wart-like" tumor, by the typical histologic finding of local invasion with only minimal, if any, dysplasia and by the unique biological behavior with low incidence of metastases and good prognosis. For proper diagnosis, both careful physical examination and deep surgical biopsy must be performed. Radical resection is the treatment of choice with histologically confirmed tumor-free resection margins. Lymphadenectomy should only be performed in case of suspicious lymphadenopathy.

CONCLUSIONS

Verrucous carcinoma may present a difficult diagnostic problem. After complete surgical resection, it has a good prognosis.

Squamous cell carcinoma of the foot

BACKGROUND

Squamous cell carcinomas (SCC) of the foot are relatively common, but have been infrequently reported in the orthopaedic literature.

MATERIALS AND METHODS

Twelve patients with SCC of the foot treated at a single institution from 1998 to 2005 were studied retrospectively with regard to risk factors for the disease, treatment, and functional and oncologic outcomes. The mean duration of postoperative followup was 43 (range, 24 to 105) months.

RESULTS

Eight of the 12 patients had identifiable risk factors for SCC. Inadequate or inappropriate procedures had been previously performed in eight of the 12 cases, requiring more aggressive definitive treatment in at least four cases. Definitive operative treatment consisted of wide excision (4 patients), partial or complete toe amputation (4), partial foot amputation (3), and transtibial amputation (1). Two patients developed local recurrence of disease, and both ultimately required Syme amputations for local control. One patient with local recurrence died of metastatic disease and the other 11 patients are alive without evident disease. Musculoskeletal Tumor Society functional scores averaged 90 and were good or excellent in nine of the 11 surviving patients.

CONCLUSION

Squamous cell carcinomas of the foot are likely underreported and frequently subject to inappropriate initial treatment. Most patients have identifiable risk factors for SCC that can aid in formulating an appropriate differential diagnosis. Despite frequent suboptimal initial treatment, most patients are candidates for complete or partial limb salvage, with generally good oncologic and functional outcomes expected.

Carcinoma cuniculatum of the jaw: a rare variant of oral carcinoma

Carcinoma cuniculatum is a rare variant of carcinoma usually involving the foot. Only 13 cases have been described in the oral cavity, none of which was in the English-language literature. We describe a 56-year-old man who presented with a soft exophytic mass in the maxillary gingiva, alveolar bone destruction, and loosening of the teeth. Histopathologic study revealed thin papillary projections covered by a thick keratin layer in the superficial areas and multiple, branching keratin-filled crypts surrounded by well-differentiated squamous epithelium with only mild cytologic atypia but frequent mitosis. Immunohistochemistry results of p53 and polymerase chain reaction analyses for human papillomavirus 6, 11, 16, and 18 DNA were negative. The diagnosis was carcinoma cuniculatum of the jaw. The literature on this unusual oral pathosis is reviewed and the diagnostic challenge described. We suggest that carcinoma cuniculatum may sometimes be misdiagnosed as squamous cell carcinoma or verrucous carcinoma and, therefore, might be more prevalent than the small number of published cases implies.

Verrucous carcinoma of the foot: a review and report of two cases

Verrucous carcinoma is an uncommon form of squamous cell carcinoma. Clinical and histological features of this condition are reviewed. Excision is the treatment of choice due to local aggressiveness and infrequent metastasis. Two cases involving the foot are presented as well as a survey of previously documented cases of this condition.

Mohs micrographic surgery for skin cancer

Mohs micrographic surgery is a reliable outpatient surgical method of removing skin cancer. The method includes tissue excision in thin layers, colour-coding of excised specimens, accurate orientation of excised tissue through construction of tissue maps, and microscopic examination of horizontal frozen sections. Selected basal and squamous cell carcinomas are treated most commonly by this method, however, a variety of less common tumors are also amenable to treatment. Mohs micrographic surgery offers the highest cure rates for selected malignancies while maintaining maximal preservation of normal tissue and important anatomic structures.

Carcinoma cuniculatum (verrucous carcinoma) of the foot

A patient with carcinoma cuniculatum of the foot, an uncommon tumor, is presented. This tumor, also reported as verrucous carcinoma and epithelioma cuniculatum, is a low-grade, squamous cell carcinoma of the skin that rarely metastasizes. The highly keratinizing lesion has a locally destructive course, but with treatment by excision, it has a low recurrence rate.

Verrucous carcinoma arising in ulcerative lichen planus of the soles

Verrucous carcinoma is a low-grade squamous cell carcinoma. Chronic inflammation is an important factor in its pathogenesis. This is the first case of plantar verrucous carcinoma arising in a lesion of ulcerative lichen planus. This paper also lends further support to the successful use of Mohs micrographic surgical technique as the treatment of choice for verrucous carcinoma.

Epithelioma cuniculatum (carcinoma cuniculatum) of the thumb: a case report and literature review

Epithelioma cuniculatum is a rare, slow growing, but locally destructive, low-grade epithelioma of squamous cell origin. The first case of this tumor occurring on the thumb is reported. Treatment of this case is discussed, the literature reviewed, and controversy surrounding the naming of this tumor is examined.

Verrucous carcinoma of the back

A case of verrucous carcinoma occurring on the dorsolumbar region of the back is reported. Verrucous carcinoma, although usually appearing on three leading sites (pan-oral, genitogluteal, and plantar), can exceptionally arise anywhere on the skin surface. It is important to be aware of this fact for more accurate diagnosis and treatment.

Surgical and aesthetic considerations of cancer of the skin in the black American

Until recently, cancer of the skin in blacks has been thought to be quite rare. This paper reviews some of the recent findings from several large series of black patients with skin cancer at our institution. Surgical management of representative cases is illustrated.