Penis and scrotum - Verrucous carcinoma

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Penis and scrotum

Squamous cell carcinoma and variants

Verrucous carcinoma

Reviewers: Antonio Cubilla, M.D. and Alcides Chaux, M.D. (see Author/Reviewers page)

Revised: 27 May 2010, last major update May 2010

Definition

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● Verruciform, slow growing, extremely well-differentiated variant of squamous cell carcinoma with low malignant potential

● ICD-O: 8051/3

Terminology

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● Also called Buschke-Löwenstein tumor

Epidemiology

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● Represents 3-8% of all penile carcinomas (Anal Quant Cytol Histol 2007;29:185) and 12-38% of all verruciform tumors

● Median age 57 years

Sites

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● Glans is the preferred site but there is occasionally extension to other compartments

● Tends to be multicentric in foreskin

Etiology

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● Consistently HPV negative (Mod Pathol 1992;5:48), or only rarely HPV+ when applying strict diagnostic criteria (Am J Surg Pathol 2010;34:104)

Clinical behavior

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● Many cases classified as verrucous carcinoma could be reclassified as other verruciform neoplasms

● Slow growing, but may recur locally

● No inguinal nodal metastases and no death due to disease in pure verrucous carcinoma

Treatment

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● Partial or total penectomy

● Possibly intra-arterial chemotherapy (Urology 2003;61:1216)

Clinical images

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Gross description (Macroscopy)

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● Broad-based white-to-gray exophytic neoplasm with a verruciform pattern of growth

● Invasion is usually limited to lamina propria or superficial corpus spongiosum

Gross images

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A large, destructive, cauliflower-like mass

has extensively replaced the penis.

Cut section shows a papillary lesion involving the glans with extension to coronal sulcus and foreskin. In the diagram (right) the tumor is represented in yellow and landmarks are indicated as follows: f-foreskin, cos-coronal sulcus, ca-carcinoma, gl-glans, cs-corpus spongiosum, cc-corpus cavernosum. Note the bulbous, pushing contour of the tumor base.

Micro description (Histopathology)

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● Very well differentiated with prominent intercellular bridges, minimal atypia and rare mitotic figures

● Penetrates through lamina propria with broad base and pushing borders

● Hyperkeratotic and acanthotic papillae with keratin cysts

● Orthokeratosis more prominent than parakeratosis

● Tumor cells are polygonal squamous cells with glassy cytoplasm, central vesicular nuclei, intercellular edema; may have superficial vacuolated clear cells but no koilocytosis

● Dense inflammatory infiltrate may obscure tumor-stroma boundary

● Intraepithelial abscess and crust formation is common

● Frequently associated with squamous hyperplasia and differentiated penile intraepithelial neoplasia

● Central fibrovascular cores are uncommon

Micro images

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Nests of well differentiated Pushing border

keratinized tumor cells

Minimal atypia

Fig A: Whole mount shows pronounced exophytic tumor. The lesion is well differentiated with hyperkeratosis, papillomatosis and acanthosis.

Fib B: The interface between the neoplasm and the lamina propria is sharp, and the bases of the squamous tongues are broad and blunt.

Fig C: The tumor cells have bland cytologic features.

Contributed by Dr. Alcides Chaux and Dr. Antonio Cubilla:

Mixed (hybrid) usual-verrucous carcinoma: Exophytic growth with marked acanthotic,

a verrucous carcinoma (upper right field) hyperkeratotic papillae. Fibrovascular

intermingled with a high-grade solid cores are inconspicuous, tumor base is

usual type squamous cell carcinoma broad and well-defined, and stromal

(lower left field) reaction is evident.

Acanthosis with marked hyperkeratosis and inconspicuous fibrovascular cores. Neoplastic cells are well-differentiated with minimal basal/parabasal atypia. Tumor front is broad-based and there is moderate chronic inflammation in underlying stroma.

Negative stains

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● Low/negative p16INK4a and Ki-67 (Mod Pathol 2009;22:1160)

Differential Diagnosis

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● Giant condyloma: conspicuous koilocytosis, prominent fibrovascular cores

● Hybrid verrucous carcinoma: foci of usual squamous cell carcinoma intermingled with a typical verrucous carcinoma

● Papillary carcinoma: invasive and jagged border, more atypia, irregular but usually evident fibrovascular cores

● Squamous hyperplasia: no atypia, no stromal reaction, no extension beyond lamina propria (in some cases distinction is not possible)

● Warty carcinoma: koilocytotic change present, jagged tumor front, neoplastic cells with more pleomorphism, prominent fibrovascular cores, usually deeper invasion

End of Penis and scrotum > Squamous cell carcinoma and variants > Verrucous carcinoma

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