Vulva
Malignant neoplasms
Verrucous carcinoma

Author: Priya Nagarajan, M.D., Ph.D. (see Authors page)
Editor: Sara Peters, M.D., Ph.D.

Revised: 10 October 2017, last major update December 2014

Copyright: (c) 2002-2017, PathologyOutlines.com, Inc.

PubMed Search: Verrucous carcinoma [title] vulva

Cite this page: Nagarajan, P. Verrucous carcinoma. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/vulvaverrucous.html. Accessed October 19th, 2017.
Definition / general
  • Not a common tumor
  • Verrucous carcinoma was first described in 1948 in the oral cavity (Surgery 1948;23:670)
  • Though verrucous carcinoma has traditionally been considered to be in the spectrum of giant condylomas histologically, recent studies have suggested that verrucous carcinomas are distinct entities with a non human papillomavirus (HPV) etiology (Am J Surg Pathol 2004;28:638, Int J Gynecol Cancer 2003;13:317)
Epidemiology
Sites
  • Most commonly affected sites are labium majora > labia minora > posterior commissure
Etiology
Clinical features
  • Slow growing firm mass, usually accompanied by pruritus and occasionally pain and discharge (especially if large, ulcerated or infected)
Diagnosis
  • Histologic examination alone can be misleading due to superficial sampling or lack of an obvious invasive component
  • Therefore, clinical history indicating exophytic tumor in an elderly woman is often helpful
Radiology description
Radiology images

Images hosted on other servers:
Missing Image Missing Image

Abdominal pelvic CT

Prognostic factors
  • Most important prognostic factors are depth of invasion and surgical margin status
  • Local recurrence is common (30 - 50%), especially after resection with inadequate margins (Br J Dermatol 2000;142:1195)
Case reports
Treatment
  • Usually excision by partial, simple or radical vulvectomy, with or without inguinal or femoral lymphadenectomy
  • Local radiotherapy may be used as an adjuvant but has been associated with development of higher grade squamous cell carcinoma
  • Systemic acitretin treatment (dose: 25 mg/day, for 4 - 6 weeks) is effective, with tumor regression in most patients (Br J Dermatol 2000;142:1195)
  • Chemotherapy (cisplatin, bleomycin, methotrexate and leucovorin) (Eur J Gynaecol Oncol 2011;32:680)
Gross description
Gross images

Images hosted on other servers:
Missing Image

Vulvectomy

Microscopic (histologic) description
  • Exo-endophytic, well circumscribed tumor composed of closely packed papillary structures lined by well differentiated stratified squamous epithelium, with minimal cellular atypia
  • By definition, no invasion by clusters or single tumors cells should be present
  • Epithelium demonstrates prominent acanthosis with (bulbous) expansion of rete ridges that push into the dermis / submucosa with rounded borders or a broad front
  • In tangentially cut sections, the tumor is composed of large, back to back nests of well differentiated squamous epithelium
  • Massive hyperkeratosis and parakeratosis is present
  • Cells have abundant pale, eosinophilic cytoplasm with low nuclear to cytoplasmic ratio, no / mild nuclear pleomorphism, basally located mitotic figures
  • Mild to moderate chronic inflammation in stroma is common
  • If infection / ulceration, neutrophils may be prominent
  • Lymphovascular and perineural invasion are extremely rare
  • Coexisting non human papillomavirus (HPV) associated carcinomas of higher grade or precursors are not uncommon and should therefore be ruled out (Am J Surg Pathol 2004;28:638)
  • Background lichen simplex chronicus with diffuse verrucous features or lichen sclerosus may be seen; VIN is not usually present
Microscopic (histologic) images

Images hosted on other servers:
Missing Image

Globoid projections

Missing Image

Exophytic growth

Missing Image

Mild atypia



Images contributed by Dr. Priya Nagarajan:

Cytology description
Positive stains
  • Ki67 proliferation index is variably increased but in 70 - 80% of cases, Ki67 expression is localized to basal layer of squamous epithelium
Negative stains
Molecular / cytogenetics description
Differential diagnosis
  • Giant condyloma acuminatum: predominantly exophytic; human papillomavirus (HPV) associated cytopathic effects of koilocytes (wrinkled or raisinoid nuclei, perinuclear halo, multinucleation, suprabasal mitoses) are easily identified; HPV nucleic acids demonstrated by in situ hybridization (Arch Gynecol Obstet 2013;287:1047)
  • Other keratinizing squamous cell carcinomas: demonstrate at least focal stromal invasion by single cells or small clusters of tumors cells; cellular atypia may be prominent; variable differentiation; rare metastases to regional lymph nodes