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

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.

Cutaneous verrucous carcinoma: A clinicopathological study of 21 cases with long-term clinical follow-up

BACKGROUND

Cutaneous verrucous carcinoma (CVC) is a rare variant of squamous cell carcinoma and sometimes shares similar clinical and histopathological features with other verrucous lesions.

METHODS

We performed a retrospective study of 21 patients diagnosed with CVC between 2012 and 2022 by reviewing clinical and histopathological data. We also compared the clinicopathological features of patients with CVC, giant condyloma acuminatum (GCA), and pseudoepitheliomatous hyperplasia (PEH). We obtained follow-up data by reviewing medical records and telephone interviews.

RESULTS

The average age of patients with CVC was 63.6 years, with a male predominance. The location of disease is mostly found in the foot, followed by the lower legs. Histologically, CVC is characterized by an exo-endophytic growth pattern with severe keratinization and a blunted rete ridge with pushing margins. Clinical features including exudation and crusting, induration, irregular borders, and warty surface, as well as pathological features including growth pattern, koilocytotic cells, depth and morphologic features of acanthosis, severe keratinization, and degree of dermal inflammation, were significant in distinguishing cutaneous CVC, GCA, and PEH.

CONCLUSION

Identification of the clinicopathological features is essential to distinguish CVC from its mimics and to make an early diagnosis. Because of the potential for recurrence and metastasis, CVC requires aggressive treatment.

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.

Update on human papilloma virus - part I: epidemiology, pathogenesis, and clinical spectrum

Infection with human papilloma virus (HPV) is related to a great number of cutaneous and mucosal manifestations. The spectrum of HPV ranges from inapparent infections, through various clinical benign presentations including cutaneous and mucosal disease, to malignant and premalignant conditions. New HPV types are currently described in the literature; many of them are characterized as high-risk types due to their oncogenic potential. Knowledge regarding their epidemiology and pathogenesis is important to understand not only infection and disease processes, but also to formulate the clinical and laboratory basis for diagnosis, therapeutics, and prophylactic measures. This non-systematic review aims to discuss and to update those aspects, with an emphasis on relevant topics for dermatologists. HPV infection and related diseases in the Brazilian scenario are highlighted, including common dermatologic conditions seen at clinics as well as the condition of a public health problem as a sexually transmitted infection. The oncogenicity of the virus and the variety of clinical outcomes - especially in the immunocompromised individuals - are addressed.

Verrucous Carcinoma of the Nail Bed: A New Case

Verrucous carcinoma (VC) of the nail bed is a rare variant of squamous cell carcinoma that is often misdiagnosed as a benign condition. The clinical presentation of this tumor is very similar to that of warts or onychomycosis hence the delayed appropriate treatment. Its association with human papillomavirus (HPV) infection has rarely been reported. The treatment of VC of the nail unit depends on the extent of the lesion and the presence or the absence of bone. We here report an unusual case of VC of the nail bed of the left big toe in a man associated with HPV53 infection that had been mistaken for a wart for 1 year. The condition was treated by ray amputation.

Nonhealing Wounds with Verrucous Presentation in the Neuropathic Patient: A Report of Two Cases

Verrucous skin lesions on the feet of diabetic patients in conjunction with a neuropathic foot ulcer is an uncommon incident. Currently, there are approximately 20 reported cases in the literature. Herein we report two cases of verrucous lesions superimposing a chronic diabetic ulcer. Patients failed several conservative treatments, and several biopsies were performed with inconclusive results, suggesting possible underlying verrucous carcinoma. Given the possibility of underlying malignancy, both patients were treated with wide excision, and both were negative for malignancy, thus confirming verrucous skin lesions on the feet in diabetic neuropathy. We also summarize the current literature on verrucous skin lesions on the feet in diabetic neuropathy.

A case series of verrucae vulgares mimicking hyperkeratosis in individuals with diabetic foot ulcers

BACKGROUND

Diabetic foot ulcers are a common complication in the advanced stages of diabetes mellitus. Certain lesions may be refractory to usual treatments with prolonged healing. In these cases, differential diagnoses to classical ulcers should be considered. Although plantar warts are a common and easy-to-diagnose finding in the general population, diagnosis can be challenging in people with diabetic foot ulcers, as they mimic hyperkeratosis in these people.

CASE REPORT

We report seven cases of people with diabetic foot ulcers and verrucae vulgares mimicking treatment-refractory hyperkeratosis, presenting to our centre between 2014 and 2016. Diagnosis was aided by the clinical presentation, followed by dermoscopy and punch biopsy. Treatment included topical application of 5-fluoruracil and salicylic acid (four people), cryotherapy (three people) and surgical excision (three people), all in combination with local pressure offloading. In five people, the verrucae were completely removed after a mean treatment period of 9.4 months; two individuals were lost to follow-up.

CONCLUSION

Verrucae may be more common in people with diabetic foot lesions and polyneuropathy than generally assumed. Typical findings include small, pinhead-sized bleedings within and surrounding hyperkeratous lesions. These findings should alert the clinician for the potential presence of a verruca. In such cases, biopsy should be performed to enable specific diagnosis and treatment.

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.

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.

Carcinoma Cuniculatum of the Foot Invading the Bone Mimicking a Pseudo-Epitheliomatous Reaction to an Acute Osteomyelitis

Carcinoma cuniculatum is a rare variant of squamous cell carcinoma. The clinical presentation is usually a non-verrucous exophytic plaque or tumor of the plantar region with a penetration in the deep tissues. Histological examination shows a proliferation of well-differentiated keratinocytes. We describe a patient affected by a slowly enlarging tumoral lesion overlying the fifth metatarsum of the left foot. Clinical examination and radiological investigations suggested a chronic osteomyelitis and a first histological examination of a punch biopsy was suggestive of a pseudo-epitheliomatous hyperplasia. The patient underwent several cycles with systemic antibiotics without improvement. Finally, the fifth metatarso was amputated and the skin lesion was completely removed. The histological examination of the whole operatory mass allowed a diagnosis of carcinoma cuniculatum invading the bone.