Verrucous carcinoma
Ackerman tumour (oral); Buschke-Löwenstein tumour (anogenital); epithelioma cuniculatum (plantar); papillary squamous cell carcinoma (cutaneous)
Verrucous carcinoma is an exceptionally well-differentiated, slow-growing variant of squamous cell carcinoma characterised by exophytic warty growth, locally destructive infiltration ("pushing" border), and a very low risk of regional or distant metastasis. Three classical clinicopathological variants are recognised: oral (Ackerman tumour), anogenital (Buschke-Löwenstein, often HPV-6/11-driven), and plantar (epithelioma cuniculatum). Surgical excision is curative; radiotherapy is controversial historically because of reports of anaplastic transformation, although modern series do not consistently demonstrate this risk.
Subtypes
- Oral (Ackerman tumour) — buccal mucosa, gingiva, alveolar ridge. Strong association with smokeless tobacco. White cauliflower-like plaque.
- Anogenital (Buschke-Löwenstein / giant condyloma) — vulva, perianal, penis. HPV-6 and HPV-11 in >80%. Cauliflower-like exophytic mass; may fistulate to bowel/rectum.
- Plantar (epithelioma cuniculatum) — sole; deep keratin-filled sinuses ("rabbit-burrow") on cut section. Often misdiagnosed as plantar wart for years.
- Cutaneous (papillary cSCC) — extremities, scalp; chronic inflammatory or scarred skin; HPV variable.
Clinical features
- Slowly enlarging, exophytic, warty/cauliflower-like plaque or nodule.
- White, malodorous, may discharge from sinuses.
- Pain, bleeding, deep tissue or bony invasion when long-standing.
- Often misdiagnosed for years as a benign wart, callus or chronic infection — index of suspicion for a non-healing or unusually large warty lesion is essential.
Histology & HPV
- Well-differentiated keratinocytes with minimal cytological atypia.
- Broad, blunt, "pushing" deep margin — invasive but not infiltrative.
- Hyperkeratosis, parakeratosis, prominent keratin pearls.
- Diagnosis often requires deep, generous biopsy — superficial samples may show only verrucous hyperplasia.
- HPV testing helpful in anogenital and oral lesions; HPV-6/11 are typical of Buschke-Löwenstein, though areas of conventional SCC (hybrid / transformed tumours) imply more aggressive behaviour.
Management
- Wide surgical excision — first-line, including periosteum or bone if invaded. Mohs micrographic surgery for plantar lesions to preserve weight-bearing surface.
- Anogenital: wide excision with sphincter-sparing reconstruction; collaborative colorectal/gynaecological surgery for large or fistulating lesions.
- Sentinel node biopsy not routinely indicated — metastatic risk is low.
- Radiotherapy: traditionally avoided due to historical reports of anaplastic transformation, but modern series suggest this concern may be overstated; can be used for inoperable cases.
- Topical 5-FU, imiquimod, intralesional interferon — adjunctive only.
- HPV vaccination has a role in primary prevention of anogenital disease.
Prognosis
Excellent with complete surgical excision. Local recurrence common if margins inadequate. Regional or distant metastasis is rare (<5%) but increases markedly with hybrid/transformed tumours containing conventional SCC areas. Long-term surveillance recommended for fields of HPV-driven anogenital disease.
References
- Schwartz RA. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol; 1995.
- Krishnamurthy S et al. Verrucous carcinoma — a clinicopathological review. Indian J Surg; 2018.
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