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Penis and scrotum
Squamous cell carcinoma and variants
Warty carcinoma
Editors: Antonio Cubilla, M.D., and Alcides Chaux , M.D. (see Authors page)
Revised: 13 May 2010, last major update January 2010
Copyright: (c) 2002-2010, PathologyOutlines.com, Inc.
Definition
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● HPV-related low-grade verruciform tumor, identical to vulvar, cervical or anal counterparts
Terminology
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● Also called condylomatous carcinoma
Epidemiology
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● 7-10% of penile carcinomas (Anal Quant Cytol Histol 2007;29:185), 34-36% of verruciform carcinomas
● Mean age 48-55 years
Sites
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● Affected sites include glans, foreskin and coronal sulcus
● Usually affects multiple anatomical compartments
● Tends to multicentricity
Clinical features
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● Slow growing
● Lymph node metastasis in 17-18% of cases; associated with deep invasion
● Intermediate behavior between low-grade verrucous or papillary carcinomas and usual squamous cell carcinomas of penis
● May recur due to inadequate excision or multicentric disease not identified at time of surgery
● Low mortality rate (0-9%) (Am J Surg Pathol 2001;25:673, Am J Surg Pathol 2000;24:505)
Poor prognostic factors
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● Invasion of corpora cavernosa
● High grade areas
● Presence of vascular/perineural invasion
Treatment
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● Partial or total penectomy; circumcision
● Groin dissection according to risk group stratification
Gross description (Macroscopy)
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● Typical lesion is exophytic mass arising from glans; also coronal sulcus or foreskin
● Verruciform, white-tan, cauliflower-like, up to 5 cm
● May have cobblestone surface
● Endophytic cut surface
● May penetrate deep into corpus spongiosum or corpora cavernosa with broad or irregular contours
Gross images
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10-38: Fig A: exophytic, cauliflower-like
white to tan tissue replaces the glans
10-38: Fig B: Cut section shows an exophytic neoplasm covering the entire glans and extending to the foreskin. Note the characteristic undulating appearance of the neoplastic papillae. The base of the lesion is ragged and infiltrates the corpus spongiosum.
Fig C: The diagram shows the tumor in yellow, effacing the corpus spongiosum (ca), and involving the coronal sulcus (cos), tunica albuginea (alb) and foreskin (ca-f), but sparing the corpus cavernosum (cc).
Micro description (Histopathology)
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● Low-grade verruciform tumor with acanthosis, hyperkeratosis and parakeratosis
● Identical to warty carcinomas of vulva, uterine cervix or anus
● Arborescent papillary pattern with long, rounded or spiky papillae with prominent fibrovascular cores
● Conspicuous koilocytosis (increased nuclear size with hyperchromasia, wrinkling and bi- or multinucleation, perinuclear halos and individual cell necrosis) throughout entire tumor (not just surface)
● May have intraepithelial abscesses
● Early - sharply delineated interface between tumor and stroma with no invasion (non-invasive warty carcinoma)
● Later - jagged boundary between tumor and stroma (invasive warty-carcinoma)
Micro images
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10-39: Undulating, complex, hyperkeratotic High power view of papillae with hyperkeratosis,
papillae with infiltration at the base parakeratosis and koilocytotic atypia
Fig 1D: exophytic/infiltrating tumor characterized by papillary architecture
and marked cytological atypia with prominent koilocytic features
Contributed by Dr. Alcides Chaux and Dr. Antonio Cubilla:
Superficially infiltrating warty carcinoma showing conspicuous koilocytosis, nuclear pleomorphism and atypical parakeratosis. Tumor base is irregular and surrounding stromal reaction is intense.
Tumors of cervix / vulva:
Condylomatous growth pattern is shown Unlike verrucous carcinoma, warty carcinoma
On the surface. Unlike verrucous has many squamous cells displaying
carcinoma, the squamous papillae koilocytotic atypia.
contain fibrovascular cores.
Irregularly shaped nests of squamous Verruciform appearance with papillae
epithelium invading the stroma. The that contain fibrovascular cores
cytologic atypia is greater than in (from Int J Gynecol Pathol 1991;10:107)
verrucous carcinoma
At the interface with the stroma, the tumor is composed of
irregularly-shaped nests of epithelium. The squamous cells
have abundant eosinophilic cytoplasm and a moderate degree
of nuclear enlargement and pleomorphism
(from Int J Gynecol Pathol 1991;10:107)
Positive stains
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● HPV
Molecular / cytogenetics description
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● 22-100% are associated with HPV, usually HPV 16 (Am J Pathol 2001;159:1211)
Differential Diagnosis
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● Carcinoma cuniculatum: deep tumoral invaginations forming irregular, narrow, and elongated neoplastic sinus tracts connecting surface to deep anatomic structures
● Giant condyloma: benign, HPV changes only in superficial layers, no pleomorphism, no invasion
● Papillary carcinoma: no HPV changes, irregular fibrovascular cores with complex papillae, invasive jagged border; more likely to have inguinal metastases
● Verrucous carcinoma: no HPV changes; inconspicuous fibrovascular cores; broad based invasive front; no regional or distant metastases
● Warty-basaloid carcinoma: warty carcinoma mixed with basaloid squamous cell carcinoma; basaloid cells present in bottom layers of papillae or in deeply infiltrative nests; more aggressive than pure warty carcinoma
Additional references
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End of Penis and scrotum > Squamous cell carcinoma > Warty variant
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