Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 5  |  Page : 648-650  

Uncommon location of verrucous carcinoma


Department of General Surgery, SRM Medical College, Kancheepuram, Tamil Nadu, India

Date of Web Publication13-Oct-2016

Correspondence Address:
Jayabal Pandiaraja
26/1, Kaveri Street, Rajaji Nagar, Villivakkam, Chennai - 600 049, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.192148

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  Abstract 


Verrucous carcinoma is an uncommon locally invasive slow growing squamous cell carcinoma of the skin and mucous membrane. It usually appears as a raised, fungating, white cauliflower-like mass. It usually occurs in oral cavity followed by genital region. Human papillomavirus, betel nut chewing, alcohol consumption, and schistosomiasis are the accepted causes for verrucous carcinoma. The recommended treatment is wide local excision with a negative margin. Even after wide local excision, local recurrence is very high compared to squamous cell carcinoma. Until now, only one case was reported with presternal verrucous carcinoma which is a rare occurrence.

Keywords: Presternal region, verrucous carcinoma, wide local excision


How to cite this article:
Pandiaraja J. Uncommon location of verrucous carcinoma. Med J DY Patil Univ 2016;9:648-50

How to cite this URL:
Pandiaraja J. Uncommon location of verrucous carcinoma. Med J DY Patil Univ [serial online] 2016 [cited 2020 Dec 2];9:648-50. Available from: https://www.mjdrdypu.org/text.asp?2016/9/5/648/192148




  Introduction Top


Verrucous carcinoma is an uncommon low-grade squamous cell carcinoma affecting the skin and mucous membrane. It typically occurs with a male preponderance. It predominantly occurs in oral cavity followed by genital region. It carries favorable prognosis compared to squamous cell carcinoma due to the low incidence of distance metastasis.[1] Human papillomavirus (serotype 6, 11, 16, and 18), leukoplakia, poor oral hygiene, low socioeconomic status, alcohol consumption, and chronic inflammations are accepted causes for verrucous carcinoma.[2]


  Case Report Top


A 34-year-old male nonsmoker and nonalcoholic presented to Surgery Department with complaints of growth and pain over the presternal region for 4 months. There was no history of bleeding from the growth. Local examination showed 2 cm × 2 cm verrucous growth over the sternum. There was no evidence of dilated veins or surrounding hyperpigmentation. On palpation growth was warty in nature and the lesion was not adherent to underlying structure [Figure 1]. There was no evidence of regional lymphadenopathy.{Figure 1}

Provisional diagnosis made as verrucous lesion either verrucous hyperplasia or verrucous carcinoma. Complete hemogram, renal function test, and liver function test were normal. Magnetic resonance imaging (MRI) chest showed no evidence of underlying infiltration or fixation. We proceeded with wide local excision with 2 cm clear margin [Figure 2]. Histopathology examination of the lesion showed features of verrucous carcinoma which include nuclear atypia, hyperkeratotic cells with keratin plugging and keratin pearls (H and E, ×100) [Figure 3]. His postoperative period was uneventful. There was no evidence of recurrence for a period of 2 years follow-up.
Figure 1: Growth of 2 cm × 2 cm growth present over the presternal region

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Figure 2: Intraoperative picture showed wide local excision with clear margin

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Figure 3: Histopathology examination of the lesion showed nuclear atypia. Individual cells are hyperkeratotic with evidence of keratin plugging and keratin pearls (H and E, ×100)

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  Discussion Top


Verrucous carcinoma is classified into four types based on the location of the tumor. They are (1) Anogenital: Buschke–Lowenstein tumor; (2) Oral cavity: Ackerman tumor; (3) Feet: Epithelioma cuniculatum; and (4) Cutaneous sites: Papillomatosis cutis carcinoides.[3],[4] Larynx, esophagus, ear, nose, temporal bone, mandible, tongue, lip, endometrium, bladder, fingertip, and sternum are mentioned as rare sites for verrucous carcinoma reported in the literature. The recommended treatment is complete wide local excision with reconstruction. Incidence of local recurrence is very high when there is an incomplete resection or positive margins. Only one case of presternal verrucous carcinoma reported in the literature.[5]

It appears initially as a skin lesion described as a single, fungating, white flake exophytic growth, plaque without surrounding discoloration. The lesion is usually painless, but it is extremely infiltrative. It has locally destructive growth potential so that it can invade underlying deeper structures such as soft tissue, fascia, muscle, and bones.[6] It is very difficult to differentiate verrucous carcinoma from verrucous hyperplasia based on the clinical findings. Superficial biopsy may lead to false negative results, so a deeper biopsy is always necessary. Histopathological examination of verrucous carcinoma reveals tumor cells with nuclear atypia. Individual tumor cells are hyperkeratotic with evidence of keratin plugging and broad-based rete ridges.[2] Keratin pearls are the hallmark for squamous cell carcinoma. However, keratin pearls are not so common in verrucous carcinoma. Other characteristic features are infiltration of lymphocytes, histiocytes, eosinophils, and plasma cells.[7]

Verruca vulgaris, dermatofibroma, benign adnexal tumor, giant seborrheic keratosis, keratoacanthoma, eccrine poroma, and hyperkeratotic basal cell epithelioma are sharing same clinical features of verrucous carcinoma. All the above should be considered as a differential diagnosis for verrucous carcinoma.[7] Preoperative MRI is always mandatory to decide extension of resection. However, in suspected bony invasion or high-risk cases computed tomography more useful to identify bony lesion compared to MRI.[7] Since the incidence of distance metastasis is very rare routine screening for metastasis is not necessary unless metastatic symptoms present.

Wide local excision with reconstruction is the treatment of choice for verrucous carcinoma. The chance of local recurrence is very high when there is a positive margin. Intraoperative tumor margins are not always well-defined due to structural distortion of adjacent tissue.[8] Amputation is only indicated when there is aggressive invasive disease, poor vascular status, and tumor recurrences.[9] Postoperative radiation therapy is contraindicated in verrucous carcinoma because of its high incidence of poorly differentiated squamous cell carcinoma. Despite local invasiveness and recurrence, distant metastasis is rarely observed. The lungs are the most common site for distant metastasis via hematogenous spread. We report this case of presternal verrucous carcinoma because of its uncommon location. Presternal region is very rare compared to other sites. Early preoperative diagnosis with wide local excision will avoid high recurrence rate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hassona Y, Scully C. Images in clinical medicine. Verrucous tongue lesion. N Engl J Med 2015;372:2049.  Back to cited text no. 1
[PUBMED]    
2.
Samman M, Sethi N. Oral verrucous pre-malignant lesions and HPV. Clin Otolaryngol 2015;40:292-3.  Back to cited text no. 2
    
3.
Alkan A, Bulut E, Gunhan O, Ozden B. Oral verrucous carcinoma: A study of 12 cases. Eur J Dent 2010;4:202-7.  Back to cited text no. 3
    
4.
Lesic A, Nikolic M, Sopta J, Starcevic B, Bumbasirevic M, Atkinson HD. Verrucous carcinoma of the foot: A case report. J Orthop Surg (Hong Kong) 2008;16:251-3.  Back to cited text no. 4
[PUBMED]    
5.
Schön MP, Heisterkamp T, Ahrens C, Megahed M, Ruzicka T. Presternal verrucous carcinoma. Hautarzt 2000;51:766-9.  Back to cited text no. 5
    
6.
Mohamed M, Belhadjali H. Carcinoma cuniculatum of the foot arising on plantar callus. Pan Afr Med J 2014;18:306.  Back to cited text no. 6
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7.
Helm MF, Haddad F, Farah R. What is your diagnosis? Verrucous carcinoma. Cutis 2015;96:82, 89-90.  Back to cited text no. 7
    
8.
Vlahovic TC, Klimaz TL, Piemontese MK, Zinszer KM. Plantar verrucous carcinoma: An unusual case of bone invasion and osteomyelitis. Adv Skin Wound Care 2009;22:554-6.  Back to cited text no. 8
[PUBMED]    
9.
Miller SB, Brandes BA, Mahmarian RR, Durham JR. Verrucous carcinoma of the foot: A review and report of two cases. J Foot Ankle Surg 2001;40:225-31.  Back to cited text no. 9
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    Figures

  [Figure 2], [Figure 2], [Figure 3]



 

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