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

Mistaken Diabetic Ulcers: A Case of Bilateral Foot Verrucous Carcinoma

Verrucous carcinoma (VC) is a rare, low-grade, and well-differentiated variant of squamous cell carcinoma. These tumors are slow-growing and exophytic and have a negligible incidence of metastasis. Treatment is complete surgical resection, ideally by Mohs micrographic surgery, to ensure adequate clear margins. Cutaneous VC predominantly occurs on the plantar surface of the foot and rarely occurs in multiple sites. This case study describes the fourth reported occurrence of bilateral VC of the feet in a woman with chronic diabetic foot ulcers. The case provides further support for persistent wounds contributing to the development of this lesion and describes their role in the characteristic delay in diagnosis of VC.

An Unusual Presentation of Verrucous Carcinoma of the Foot with Bone Invasion

Verrucous carcinoma of the foot is a rare malignancy, and proper diagnosis can be delayed. Furthermore, misdiagnosis often results in delayed appropriate treatment. Herein, we present an unusual case of verrucous carcinoma of the fifth toe with bone invasion in a 63-year-old woman that was mistaken for a plantar wart for 3 years. The condition was treated by ray amputation. We emphasize the need for appropriate biopsy to achieve an accurate diagnosis.

A Verrucous Carcinoma of the Foot on an Injection Site: A Case Report

Verrucous carcinoma of the foot, also known as epithelioma cuniculatum, usually occurs on the inner aspect of the foot. It is a slow-growing variant of squamous cell cancer with a low metastatic potential. This case report presents a patient with a verrucous carcinoma of the foot who had been receivin long-term intralesional triamcinolone acetonide in that site for some steroid-responsive dermatosis, presumably lichen simplex chronicus.

Verrucous Carcinoma - Observations on 4 Cases

Verrucous carcinoma (VC) is a rare well-differentiated squamous cell carcinoma with the clinical forms: oral florid papillomatosis, epithelioma cuniculatum, papilomatosis cutis and Buschke-Löwenstein tumor. We present four patients and the four clinical forms of CV. The diagnosis we held after clinical examination and histopathological examination of the balance sheet expansion. First described by Ackermanin the oral mucosal, today it has a reported incidence of 1-3 cases per million inhabitants. CV can involve both skin and mucous membranes. Etiopathogenesis is uncertain, but participation HPV is widely accepted. WHO recognizes the CV as a rare form of well-differentiated squamous cell carcinoma with slow and continues evolution, with the invasion of underlying tissues, frequent relapses and very low risk of metastasis. The elective therapy is surgical excision with safety oncological margins. Diagnosis involves corroboration of clinical data with histopathological appearance and evolutive behavior of the tumor. Given the increased risk for recurrence, the patient should be reviewed quarterly to finding healing.

A Rare Case of Plantar Epithelioma Cuniculatum Arising from a Wart

A 68-year-old man, a known case of hypertension, coronary artery disease and old cardiovascular accident with right-sided hemiplegia, came with the chief complaints of a large cauliflower like growth with pus discharge on the left heel since 15 years. The patient had sustained a penetrating injury by a thorn on the left heel region few days before the lesion appeared. Dermatological examination revealed a single verrucous lesion measuring 7 × 7 cm on the left heel region associated with discharge of foul smelling cheesy material. There was also a enlarged right inguinal lymph node which was non-tender, firm, measuring 2 cm in diameter with normal overlying skin. X-ray left ankle was done which showed some soft tissue swelling. A skin biopsy showed hyperkeratosis, acanthosis and parakeratosis. Elongated rete ridges with keratinocyte hyperplasia, forming a large mass pressing on the underlying dermis were seen. There was formation of multiple large keratin filled invaginations and crypts. No atypical cells were seen. Based on history, clinical examination and investigations, a diagnosis of epithelium cuniculatum type of verrucous squamous cell carcinoma was made. A wide excision with a flap cover was performed in consultation with the oncosurgeon and the excision sample was sent for histopathological re-examination, which confirmed the diagnosis of epithelioma cuniculatum.

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.

An unusual case of bilateral verrucous carcinoma of the foot (epithelioma cuniculatum)

Verrucous carcinoma is a rare, well-differentiated variant of squamous cell carcinoma with a minimal incidence of metastasis. Conservative treatment and local excision have been utilized although with high recurrence rates. We present a unique case of a 44-year-old male with bilateral foot involvement with recurrences after local excision, leading to management with bilateral forefoot amputations.

[Verrucous tumor of the amputation stump]

Epithelioma cuniculatum (EC) belongs to the category of verrucous carcinomas. Invasiveness and rate of metastasis are low, but there is a high risk of local recurrence. In cases of long-standing processes with formation of exophytic, malodorous tumors with jagged edges that do not respond to conventional therapy, consideration should already be given to EC upon visual inspection. The diagnosis is always established by histological examination. The standard treatment of EC is extensive excision of the tumor with micrographic margin control.

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.

Dermatopathology in Historical Perspective: Epithelioma Cuniculatum (Aird)

Professor Ian Aird, a renowned British surgeon of the mid-twentieth century, described a peculiar neoplasm of the foot in 3 patients under the term epithelioma cuniculatum, now more commonly called carcinoma cuniculatum. I will recount the life of Professor Aird and then summarize his original report emphasizing the clinical and more particularly the histopathologic criteria of epithelioma cuniculatum as described by Aird et al. Then I will summarize some of the subsequent reports of epithelioma (carcinoma) cuniculatum. Authors have grouped carcinoma cuniculatum with giant condyloma of the penis of Buschke-Loewenstein and oral verrucous carcinoma of Ackerman and similar neoplasms at other sites under the generic title "verrucous carcinoma." Although this classification has been accepted, I will stress that the clinical picture and histopathology described by Aird et al differ from those in later reports of carcinoma cuniculatum. These correspond to descriptions of the verrucous carcinomas of Buschke-Loewenstein and Ackerman. Finally, I will conclude that carcinoma cuniculatum as delineated by Aird and his colleagues is an extremely rare, indolent, nonmetastasizing squamous cell carcinoma composed of banal keratinocytes with unique clinical and histopathologic features that almost always arises on the foot. If a neoplasm on the foot has the characteristics of verrucous carcinoma that occurs at others sites, but not those of Aird et al, it should be called verrucous carcinoma of the foot, and not "epithelioma (carcinoma) cuniculatum."