Verrucous carcinoma presenting as recalcitrant verruca plantaris.

Verrucous carcinoma (VC) is a rare, low-grade variant of well-differentiated squamous cell carcinoma. Plantar verrucous carcinoma presents as a slow-growing, exophytic, verrucous plaque on weight bearing areas of the foot. Verrucous carcinomas have low metastatic potential, but are high risk for local invasion. We describe a patient with a 20-year history of a slowly growing, ulcerated, verrucous plaque on the sole of the left foot that was erroneously treated for years as verruca plantaris and was eventually diagnosed as invasive verrucous carcinoma. Verrucous carcinomas are a diagnostic challenge due to clinical and histopathologic mimicry of benign lesions. Mohs micrographic surgery should be employed to allow the ability to intraoperatively assess tumor margins while excising the minimal amount of necessary tissue. It is important for clinicians to recognize the characteristics and accurately diagnose verrucous carcinomas. Delays in treatment may require more extensive dissection or amputation.

Cutaneous Verrucous Carcinomas: A Review.

Verrucous carcinoma (VC) is a relatively rare locally aggressive, slow-growing, well-differentiated squamous cell carcinoma with minimal metastatic potential and is most frequent in the mucosa. Although rarely reported on the skin, cutaneous verrucous carcinomas (CVC) can appear anywhere, most commonly on the feet. However, clinical and pathologic diagnosis of CVC has been confusing and challenging. It can easily be mistaken for benign or more malignant conditions such as giant condyloma acuminata, keratoacanthoma, and pseudoepithelioma-like hyperplasia or squamous cell carcinoma, resulting in inappropriate management. In this review, we describe the different aspects associated with CVC, including its pathogenesis and clinicopathologic features. The available evidence for the differential diagnosis and treatment of CVC is discussed, and specific management recommendations are made. After the treatment, careful follow-up examinations of the excised area should be performed at regular intervals.

Verrucous carcinoma of the esophagus - a case report and literature review.

BACKGROUND: Verrucous carcinoma of the esophagus is a rare disease leading to dysphagia, chest pain, and weight loss. The diagnosis is difficult because even repeated biopsies are often without tumor evidence. We present a patient with verrucous carcinoma of the esophagus and a literature review. CASE REPORT: A 64-year-old patient with dysphagia and sore throat received esophagogastroduodenoscopy illustrating segmental circumferential verrucous inflammation and Candida esophagitis in the middle part of the esophagus. Repeated mucosal biopsies revealed reactive hyperkeratosis of the squamous epithelium with minimal atypia but without ulcera, eosinophilic esophagitis, or suspicion of cancer. Mucosal infection with adenovirus, herpes simplex virus 1, human papilloma virus types, and cytomegaly virus was ruled out. Veruccous carcinoma was detected finally by endoscopic mucosal resection. The patient was successfully treated by esophageal resection. Tumor stage was G1, pT1b, pN0, L0, V0, Pn0, R0. CONCLUSION: The results suggest that macroscopic suspicion of verrucous esophageal carcinoma should lead to resections of larger tissue specimens by EMR to confirm the diagnosis.

Complex abdominopelvic reconstruction by combined tensor fascia latae and superficial circumflex iliac artery perforator flaps.

BACKGROUND: Extensive full thickness abdominopelvic defects pose a difficult challenge to surgeons. Autologous tissues are versatile and can provide a satisfying reconstructive option for this type of defects. The tensor fascia latae (TFL) and superficial circumflex iliac perforator (SCIP) flaps provide a large area of vascularized tissue and their use in reconstructive surgery is well-known. In this report, the authors present the experience of using combined TFL and propeller SCIP flaps for covering large abdominal and pelvic defects. METHODS: Four patients underwent reconstruction of soft-tissue abdominopelvic defects by combined TFL and SCIP flaps. Three were men and one woman, aged from 52 to 76 years. The etiologies of the defects were tissue loss after tumor resection in 3 cases and necrotizing fasciitis in the fourth case. Defect dimensions ranged from 32 × 20 cm to 45 × 17 cm. An acoustic handheld Doppler was utilized to detect perforator vessels, then TFL and SCIP flaps were elevated at the same time by 2 surgical teams. Donor sites of the flaps were closed primary except for one TFL flap donor site. The latter one was treated with negative pressure therapy and finally with a split-thick skin graft. RESULTS: The size of the TFL flaps ranged from 25-38 × 10-14 cm. Concerning the SCIP flaps, the dimensions ranged from 18-32 × 12-18 cm. The average flap dimensions were 30.25 × 11.75 cm for the TFL and 26.75 × 14 cm for the SCIP. Two TFL flaps presented a necrosis of the distal tip. All the other flaps survived entirely. Complete healing was achieved in all patients. Patients were followed for an average of 4 months postoperatively (ranging between 2 and 8 months). CONCLUSIONS: Combined TFL and SCIP flaps may represent an alternative reconstructive procedure for large abdominopelvic defects in well-selected cases.

[Clinicopathological features and management of penile verrucous carcinoma].

OBJECTIVE: To explore the clinicopathological characteristics, diagnosis and treatment of penile verrucous carcinoma (VC). METHODS: We retrospectively analyzed the clinical data about 18 penile VC patients at the mean age of 52 (35－66) years. The tumors were cauliflower-like, measuring 2.5－8.7 cm in diameter, all with mucopurulentive discharge. A giant tumor invaded the perineum in 1 case, which had a history of surgical excision of penile condyloma acuminatum. The lesions invaded the glans penis in 2 cases, the shafts in 4 (all with a history of phimosis or redundant prepuce), and the whole penis in 11. Partial penectomy was performed for 2 cases with the proximal coronary sulcus involved and another 2 with the condylomata located in the glans penis and measuring <3.5 cm in diameter. Radical surgery was done for 2 cases of glans VC >3.5 cm in diameter, 11 cases with the whole penis involved, and 1 case with the perineum invaded. RESULTS: Postoperative pathology showed well-differentiated tumor cells, negative surgical margins, papillary epithelia with hyperkeratosis and hyperplasia, and lymphocyte infiltration in the surrounding interstitial tissue in all the cases. Neither recurrence nor metastasis was found during the 1 to 8 years of follow-up. CONCLUSIONS: Penile VC is a special type of squamous cell carcinoma with little invasiveness and rare regional lymph node or distant metastasis, for the treatment of which partial penectomy or radical surgery confers good prognosis.

Utility of Superiorly Based Masseter Muscle Flap for Postablative Retromaxillary Reconstruction.

PURPOSE: Resections in the posterior component of the oral cavity usually lead to severe functional compromise and lower quality of life for patients. Notable advances in reconstruction of the posterior part of the mouth and of the oropharynx have occurred in recent decades. The anatomic and physiologic rehabilitation of the defect to a reasonable outcome with low morbidity and mortality remains the founding basis of any surgical reconstruction, which also holds true for oral oropharyngeal and retromaxillary reconstructions. PATIENTS AND METHODS: A retrospective chart review study of all patients who underwent surgery for retromaxillary malignancy at the Department of Oral and Maxillofacial Surgery, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital (Nagpur, India) from 2006 to 2015 was performed. Patients underwent selective neck dissection of levels I to IV using wide local excision. The decision for the type of maxillary resection (marginal ostectomy, partial posterior maxillectomy, or hemimaxillectomy) depended on the degree of osseous infiltration of the tumor. Reconstruction was performed in all cases using the regional masseter muscle flap and advancement of the palatal flap into the defect. The necessary findings and observations were tabulated. RESULTS: Of 76 patients who presented at the hospital, 69 had biopsy specimens positive for squamous cell carcinoma and 7 had biopsy specimens positive for verrucous carcinoma. Twenty-three patients with lesions extending and encroaching into the infratemporal fossa or skull base, distant metastasis, or guarded prognosis were not included in the study. Also excluded from the study were those patients in whom flaps other than the masseteric flap were used primarily for reconstruction. In the remaining 53 patients who underwent resection of retromaxillary malignancy with masseter muscle reconstruction, 48 showed a satisfactory outcome. Postoperative infection was noted in 5 patients and 2 of these patients needed debridement. Postoperative wound contracture with muscular spasm and decreased mouth opening in the early postoperative period were a general observation. In all patients, the vitality of the flap was excellent, with epithelization and adequate mouth opening within 3 weeks. Postoperative speech, swallowing, and facial esthetics were satisfactory and acceptable. CONCLUSION: The masseter muscle flap is a promising reconstruction alternative for retromaxillary reconstruction because of advantages such as regional access, ease of harvesting, optimum bulk, flexibility, pliability for larger defects, and minimum postoperative morbidity.

[A Patient with Lower Lip Verrucous Carcinoma Treated with a Tongue Flap for Functional and Esthetic Reconstruction].

Surgery is generally indicated for the treatment of lower lip carcinoma. However, surgery can lead to esthetic as well as functional issues, with disturbances in eating and articulation. If the defect involves less than one-third of the width of the lower lip, primary closure is possible. If the defect is wider, reconstructive local flaps may be necessary for both esthetic and functional recovery. This report describes a case of lower lip verrucous carcinoma in which a tongue flap was used to treat a defect involving more than half the width of the lower lip following resection. The patient was a 91-year-old woman who complained of lower lip discomfort. A biopsy revealed verrucous carcinoma, and we performed resection. After a 3-week waiting period, we performed secondary tongue flap reconstruction. Satisfactory function and cosmetic results were achieved.

Reconstruction of the Auricular Defect After Excision of Verrucous Carcinoma.

Verrucous carcinoma is a highly differentiated variant of squamous cell carcinoma with a high local recurrence rate. Few studies of primary verrucous carcinoma of the auricle have reported on the surgical outcome. The authors present herein a case in which a verrucous carcinoma of the auricle was successfully removed and reconstructed using a retroauricular pull-through island flap, and the authors briefly review the relevant literature.

A Rare Cause of Hoarseness: Laryngeal Verruca Vulgaris.

Verruca vulgaris is a cutaneous disease manifested with a single or multiple, small painless lesions that may involve keratinized or nonkeratinized epithelium. It can be localized at skin or mucosa. It is a benign lesion; however, it is of importance to discriminate from verrucous carcinoma to plan treatment, especially in those with laryngeal localization. Total excision is adequate in the management of verruca vulgaris; thus, accurate differential diagnosis is essential to avoid unnecessary surgical interventions. Here, the authors presented a patient with verruca vulgaris which was totally excised by cold-blade surgical excision.

Verrucous Carcinoma of the Vulva: A 20 Year Retrospective Study and Literature Review.

OBJECTIVE: The aim of the study was to assess the clinicopathological characteristics of patients with verrucous carcinoma (VC) of the vulva. MATERIALS AND METHODS: We reviewed data on the age, disease course, clinical manifestation, pathologic diagnosis, treatment, and follow-up of patients with vulvar VC who were treated at Tianjin Medical University General Hospital and cases that were reported in the Chinese and English literature during the past 20 years. RESULTS: Six cases were identified in Tianjin Medical University General Hospital, the mean age of patients was 55 years, and their mean disease course was 26 months. Primary symptoms were exophytic neoplasm with pruritus and/or pain. Surgical treatment included wide local excision, simple vulvectomy, and radical vulvectomy with or without lymph node dissection in the groin. Vulvar VC occurred simultaneously with vulvar intraepithelial neoplasia in 2 cases and well-differentiated squamous cell carcinoma in 2 cases. The mean follow-up was 16.8 months with no recurrence in those 6 cases. During the 20-year period, 20 and 41 cases were reported in Chinese and English literature, respectively. Three cases were misdiagnosed with giant condyloma acuminatum in China. One case (1/20) was reported with coexistent squamous carcinoma in Chinese literature and 8 cases (8/41) in the English literature. The recurrence rate was 12.5% (2/19) and 17.5% (7/40) in Chinese and English literature, respectively. CONCLUSIONS: Vulvar VC is a distinct type of slow-growing, nonmetastatic tumor with unclear etiology. These tumors should be distinguished from giant condyloma acuminatum and well-differentiated squamous cell carcinoma. Surgery is the most effective treatment.

Intraosseous verrucous carcinoma arising from an infected dentigerous cyst-A case report.

Intraosseous verrucous carcinoma (IOVC) arising from an odontogenic cyst is extremely rare. We report a case of intraosseous verrucous carcinoma in a 74-year-old male who presented with a left mandibular swelling with recurrent pus discharge from gingiva of tooth #35. Panoramic radiography revealed an impacted tooth #34 and a large well-defined, radiolucent lesion surrounding the crown of tooth #34. The clinical diagnosis was an infected dentigerous cyst. Surgical excision of the cyst together with extraction of tooth #34 was performed. Histopathological examination showed proliferation of hyperparakeratotic stratified squamous cyst lining epithelium and down-growth of broad and bulbous epithelial ridges with pushing border invasion into the fibrous cystic wall. A verrucous carcinoma arising from an infected dentigerous cyst was diagnosed. There was no recurrence of the tumor 5 months after surgery.

Verrucous carcinoma of the endometrium: a rare and challenging diagnosis.

Verrucous carcinoma of the endometrium is an exceedingly rare disease with only a few cases reported in the literature. We describe the case of a 68-year-old postmenopausal patient who presented with vaginal discharge. PAP smears were repeatedly reported negative and an endometrial curettage 2 years prior to the diagnosis only showed fragments of benign squamous epithelium. Because of continuous symptoms a hysterectomy was performed and revealed extensive squamous metaplasia of the endometrium with focal transition to verrucous carcinoma. This case demonstrates that benign appearing squamous epithelium in curettage specimens, especially when abundant, is not necessarily ordinary portio epithelium. In this setting, the clinical presentation becomes paramount for considering a well differentiated squamous carcinoma of the endometrium and avoiding diagnostic delay.

Carcinoma cuniculatum in course of etanercept: blocking autoimmunity but propagation of carcinogenesis?

Carcinoma cuniculatum (CC) or verrucous squamous cell carcinoma is a rare variant of squamous cell carcinoma with low incidence of metastasis. It mainly affects men during the fifth-sixth decade of life, arising mostly on the weight-bearing surface of the foot, but it can also be found in other body areas. The favorable effects on the psoriatic, rheumatoid, juvenile polyarthritis as well as the ankylosing spondylitis after the application of Tumour Necrosis Factor (TNF)-alpha inhibitors, like etanercept, presume the availability of similarity between the etiopathogenetic mechanisms which are responsible for the generation of the inflammatory cascade. According to the latest studies, the sensitivity of the patients to TNF-alpha inhibitors could be genetically determined and may also be due to certain genetic polymorphisms of the NLP3 and CARD8 zones of the inflammasome. The blocking of the inflammatory reaction within the borderlines of the psoriatic arthritis could also be accepted as something of a double edged sword. There is a growing volume of literary data which informs us of the clinical manifestation, not only of skin, but also of other types of tumors after the application of TNF-alpha inhibitors. This inevitably generates the hypothesis that within a certain group of patients the TNF-alpha inhibitors have some additional, and currently obscure, effects on presumably key regulatory proteins of the so-called extrinsic apoptotic pathway. Other proteins of the human inflammasome could be also implicated in the regulation of the programmed cell death and the carcinogenesis - there are speculations, that the adapter protein, ASC/TMS1, could be one of these. The present study describes the case of a patient who developed a rare form of skin tumor - epithelioma cuniculatum - whilst undergoing etanercept therapy for psoriatic arthritis. Under discussion are the possible critical connections in the complex regulatory networks of the inflammatory processes, the programmed cell death (apoptosis) and the carcinogenesis which, in the near or distant future, could become the objects of a targeted therapy.

Total lower lip reconstruction with a double mental neurovascular V-Y island advancement flap.

PURPOSE: To assess the effectiveness of double mental V-Y island advancement flaps for total lower lip reconstructions. MATERIALS AND METHODS: During a 6-year period, from 2006 to 2012, total lower lip reconstruction was performed in 12 patients using double mental V-Y island advanced flaps. The resulting lip function and superiority of each flap were analyzed. To assess any cosmetic implications, patients were asked to answer the Appearance Domain section from the University of Washington Quality of Life Questionnaire at least 12 months after discharge from the hospital. RESULTS: All flaps survived completely and no short-term postoperative complications occurred. The mean follow-up time was 34.5 months (range, 15 to 69 months) and there was no recurrence of disease. All patients were capable of consuming a regular oral diet and no patients complained of an inability to eat in a public setting, drooling, or microstomia. The mean preoperative and postoperative open-mouth widths were 4.1 and 3.7 cm, respectively, and the mean reduced open-mouth width was 10%. The intercommissural width varied from 4.6 to 6.8 cm (mean, 5.5 cm). The mean postoperative 2-point discrimination was 11.2 mm (range, 9 to 13 mm). The mean score for the Appearance Domain section was 93.8 (range, 75 to 100). CONCLUSION: The mental V-Y island advancement flap reconstruction is a reliable procedure for total lower lip reconstruction.

Carcinoma cuniculatum: an atypical presentation in the foot.

Carcinoma cuniculatum is a rarely occurring, low-grade variant of squamous cell carcinoma most commonly found in the forefoot. It should be suspected in the differential diagnosis for chronic nonhealing verrucous wounds. The initial diagnosis of carcinoma cuniculatum is difficult and often delayed and can require repeated histopathologic evaluation by an experienced pathologist. In many cases, the final diagnosis will be made from the microscopic findings correlated with the clinical examination findings. Metastasis from carcinoma cuniculatum is rare, although it can invade deep into the soft tissues and can extend to the bone. Wide local excision with a 5-mm tumor-free margin has been the recommended treatment. If the tumor extends into the bone, amputation might be warranted. The present report describes the case of an atypical carcinoma cuniculatum found in the hindfoot of an adult female and represents the surgical follow-up to the histopathologic description of the same patient's lesion as previously described in a published report.

Verrucous carcinoma of the oral mucosa: an epidemiological and follow-up study of patients treated with surgery in 5 last years.

INTRODUCTION: Oral Verrucous Carcinoma (OVC) is described apart of the Squamous Cell Carcinoma (SCC) due to its specific properties. The objective of our study is to show our series of cases of OVC and to compare with the SCC in terms of clinical manifestations, epidemiology, histopathology, treatment and follow-up. MATERIAL AND METHODS: This is a retrospective study of all the OVC treated in our department between January-2007 and December-2011. The analyzed variables were sex, age, localization in the oral cavity, histopathology, number of biopsies needed to diagnose OVC, TNM classification, treatment and recurrences during follow-up. RESULTS: Our sample was composed by n=14 patients, 57% female, with a mean age of 69.14 years. The most common localization was buccal mucosa (n=5). Seven patients were diagnosed of OVC with the first biopsy. TNM classification was: pT1: 7 patients, pT2: 3 patients, pT3: 3 patients, pT4: 1 patient. No cervical metastases were observed either in cervical neck dissection or during the follow-up of the patients. The treatment was surgery with clinical resection margins up to 1 cm in all cases, followed by radiotherapy in selected cases. Only n=1 patient (7.69%) presented a recurrence after 34 months of follow-up. The overall survival rate was 92.85%. CONCLUSIONS: In our population, OVC represents the 6.16% of all oral cavity and oropharynx cancer, and is more frequent in female patients above 70 years old. It uses to rise over a previous lesion, and usually affects the buccal mucosa. In patients with high suspicious lesions, more than one biopsy may be needed to diagnose OVC. No patient showed cervical dissemination. In our experience, treatment based on local resection, without cervical neck dissection, could be a good option for these patients.