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Verrucous Carcinoma Occurring on the Flank
J Exp Clin Med 2013;5(4):158–159
Contents lists available at SciVerse ScienceDirect
Journal of Experimental and Clinical Medicine journal homepage: http://www.jecm-online.com
LETTER TO THE EDITOR
Verrucous Carcinoma Occurring on the Flank Verrucous carcinoma is a rare well-differentiated squamous cell carcinoma of the skin and mucosa. We present a case of verrucous carcinoma in an unusual location, the flank, treated by local wide excision and rotational flap reconstruction. A 39-year-old man noticed an erythematous plaque with whitish discharge over his right flank for 1 year. The plaque gradually enlarged with intermittent swelling and pain. Three tumors then developed within the plaque and purulent secretion was noted. Physical examination revealed an indurated erythematous plaque measuring 7 cm 4 cm with three verrucous tumors measuring 1.6 cm 1.5 cm 0.5 cm, 2.4 cm 2.0 cm 0.5 cm and 2.2 cm 2.2 cm 0.6 cm. There were also two openings, draining purulent secretion, around the tumor (Figure 1A). Skin biopsy of the verrucous tumor showed architecture of inverted follicular keratosis with suspicion of malignancy, thus total excision of the plaque with a 1-cm surgical margin was performed. We used a rotational flap to cover the defect. Histopathology of the excised plaque showed both exophytic and endophytic structures with hyperkeratosis, parakeratosis, papillomatosis and acanthosis (Figure 1B). There were also glassy-appearing keratinocytes with minimal atypia and mitotic figures, accompanied by some koilocytes and enlarged clumps of keratohyaline granules. The keratinocytes extended downward into the dermis, with pushing lower borders forming some keratin-filled sinuses. Lymphocytic infiltration and some dilated capillaries were also present in the superficial dermis. The whole picture was suggestive of verrucous carcinoma. For analyzing the presence of human papillomavirus (HPV), we extracted DNA from paraffin-embedded tissue and polymerase chain reaction (PCR) amplification was performed. PCR using two universal HPV PCR primers, including GP5þ/6þ and MY09/11 could not detect any HPV sequences. We could not detect any HPV sequence by PCR using two wellestablished universal HPV PCR primers, GP5þ/6þ and MY09/11. GP5þ/6þ and MY09/11 primers detected a broad spectrum of HPV genotypes with amplification of fragments of 150 bp and 450 bp from the L1 region. Paraffin-embedded tissue was used for DNA extraction, therefore, the possibility of DNA degradation could not be completely ruled out. However, pretesting to ensure sufficient DNA was performed, and a positive control group with paraffin-embedded condyloma sample showed positive results. The treatment for verrucous carcinoma is surgery, and local wide excision is the most common treatment. Mohs surgery may be beneficial in areas where tissue-sparing is important. Other treatment modalities include cryotherapy, curettage and electrodessication, topical fluorouracil, a-interferon, methotrexate, laser therapy, photodynamic therapy, chemotherapy by oral, intralesional or iontophoretic methods, and retinoid therapy with variable results.1 Whether radiotherapy can be considered as an alternative
treatment modality for inoperable cases is still controversial due to anaplastic transformation potential of irradiated verrucous carcinoma to invasive squamous cell carcinoma. We presented a case of verrucous carcinoma in an exceedingly rare location, such as the flank. Detection of HPV DNA by PCR showed negative results. Successful treatment with wide excision
Figure 1 Verrucous carcinoma. (A) Three verrucous tumors measuring 1.6 cm 1.5 cm 0.5 cm, 2.4 cm 2.0 cm 0.5 cm and 2.2 cm 2.2 cm 0.6 cm on an indurated erythematous plaque with two openings draining purulent secretion. (B) Histopathology showed hyperkeratosis, parakeratosis, papillomatosis, and acanthosis, with well-differentiated, glassy-appearing keratinocytes, koiloctyes and enlarged clumps of keratohyaline granules (hematoxylin and eosin, original magnification 40).
1878-3317/$ – see front matter Copyright Ó 2013, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.jecm.2013.06.007
Letter to the Editor
and rotational flap reconstruction without recurrence after 1 year follow-up may be considered as a good example of surgery as the gold standard treatment modality for this tumor.
References 1. Schwartz RA. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol 1995;32:1–24.
159 3. Noel JC, Peny MO, Goldschmidt D, Verhest A, Heenen M, De Dobbeleer G. Human papillomavirus type 1 DNA in verrucous carcinoma of the leg. J Am Acad Dermatol 1993;29:1036–8. 4. Rubin MA, Kleter B, Zhou M, Ayala G, Cubilla AL, Quint WG, Pirog EC. Detection and typing of human papillomavirus DNA in penile carcinoma: evidence for multiple independent pathways of penile carcinogenesis. Am J Pathol 2001;159:1211–8.
Chien-Nien Li, Chia-Lan Ou, Shih-Wei Yeh, Pei-Shan Yen* Department of Dermatology, Taipei Medical University – Shuang Ho Hospital, Taipei, Taiwan
Further reading 1. Kraus FT, Perezmesa C. Verrucous carcinoma. Clinical and pathologic study of 105 cases involving oral cavity, larynx and genitalia. Cancer 1966;19:26–38. 2. Miyamoto T, Sasaoka R, Hagari Y, Mihara M. Association of cutaneous verrucous carcinoma with human papillomavirus type 16. Br J Dermatol 1999;140:168–9.
* Corresponding author. Pei-Shan Yen. E-mail: P.-S. Yen Apr 3, 2013
Contents lists available at SciVerse ScienceDirect
Journal of Experimental and Clinical Medicine journal homepage: http://www.jecm-online.com
LETTER TO THE EDITOR
Verrucous Carcinoma Occurring on the Flank Verrucous carcinoma is a rare well-differentiated squamous cell carcinoma of the skin and mucosa. We present a case of verrucous carcinoma in an unusual location, the flank, treated by local wide excision and rotational flap reconstruction. A 39-year-old man noticed an erythematous plaque with whitish discharge over his right flank for 1 year. The plaque gradually enlarged with intermittent swelling and pain. Three tumors then developed within the plaque and purulent secretion was noted. Physical examination revealed an indurated erythematous plaque measuring 7 cm 4 cm with three verrucous tumors measuring 1.6 cm 1.5 cm 0.5 cm, 2.4 cm 2.0 cm 0.5 cm and 2.2 cm 2.2 cm 0.6 cm. There were also two openings, draining purulent secretion, around the tumor (Figure 1A). Skin biopsy of the verrucous tumor showed architecture of inverted follicular keratosis with suspicion of malignancy, thus total excision of the plaque with a 1-cm surgical margin was performed. We used a rotational flap to cover the defect. Histopathology of the excised plaque showed both exophytic and endophytic structures with hyperkeratosis, parakeratosis, papillomatosis and acanthosis (Figure 1B). There were also glassy-appearing keratinocytes with minimal atypia and mitotic figures, accompanied by some koilocytes and enlarged clumps of keratohyaline granules. The keratinocytes extended downward into the dermis, with pushing lower borders forming some keratin-filled sinuses. Lymphocytic infiltration and some dilated capillaries were also present in the superficial dermis. The whole picture was suggestive of verrucous carcinoma. For analyzing the presence of human papillomavirus (HPV), we extracted DNA from paraffin-embedded tissue and polymerase chain reaction (PCR) amplification was performed. PCR using two universal HPV PCR primers, including GP5þ/6þ and MY09/11 could not detect any HPV sequences. We could not detect any HPV sequence by PCR using two wellestablished universal HPV PCR primers, GP5þ/6þ and MY09/11. GP5þ/6þ and MY09/11 primers detected a broad spectrum of HPV genotypes with amplification of fragments of 150 bp and 450 bp from the L1 region. Paraffin-embedded tissue was used for DNA extraction, therefore, the possibility of DNA degradation could not be completely ruled out. However, pretesting to ensure sufficient DNA was performed, and a positive control group with paraffin-embedded condyloma sample showed positive results. The treatment for verrucous carcinoma is surgery, and local wide excision is the most common treatment. Mohs surgery may be beneficial in areas where tissue-sparing is important. Other treatment modalities include cryotherapy, curettage and electrodessication, topical fluorouracil, a-interferon, methotrexate, laser therapy, photodynamic therapy, chemotherapy by oral, intralesional or iontophoretic methods, and retinoid therapy with variable results.1 Whether radiotherapy can be considered as an alternative
treatment modality for inoperable cases is still controversial due to anaplastic transformation potential of irradiated verrucous carcinoma to invasive squamous cell carcinoma. We presented a case of verrucous carcinoma in an exceedingly rare location, such as the flank. Detection of HPV DNA by PCR showed negative results. Successful treatment with wide excision
Figure 1 Verrucous carcinoma. (A) Three verrucous tumors measuring 1.6 cm 1.5 cm 0.5 cm, 2.4 cm 2.0 cm 0.5 cm and 2.2 cm 2.2 cm 0.6 cm on an indurated erythematous plaque with two openings draining purulent secretion. (B) Histopathology showed hyperkeratosis, parakeratosis, papillomatosis, and acanthosis, with well-differentiated, glassy-appearing keratinocytes, koiloctyes and enlarged clumps of keratohyaline granules (hematoxylin and eosin, original magnification 40).
1878-3317/$ – see front matter Copyright Ó 2013, Taipei Medical University. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.jecm.2013.06.007
Letter to the Editor
and rotational flap reconstruction without recurrence after 1 year follow-up may be considered as a good example of surgery as the gold standard treatment modality for this tumor.
References 1. Schwartz RA. Verrucous carcinoma of the skin and mucosa. J Am Acad Dermatol 1995;32:1–24.
159 3. Noel JC, Peny MO, Goldschmidt D, Verhest A, Heenen M, De Dobbeleer G. Human papillomavirus type 1 DNA in verrucous carcinoma of the leg. J Am Acad Dermatol 1993;29:1036–8. 4. Rubin MA, Kleter B, Zhou M, Ayala G, Cubilla AL, Quint WG, Pirog EC. Detection and typing of human papillomavirus DNA in penile carcinoma: evidence for multiple independent pathways of penile carcinogenesis. Am J Pathol 2001;159:1211–8.
Chien-Nien Li, Chia-Lan Ou, Shih-Wei Yeh, Pei-Shan Yen* Department of Dermatology, Taipei Medical University – Shuang Ho Hospital, Taipei, Taiwan
Further reading 1. Kraus FT, Perezmesa C. Verrucous carcinoma. Clinical and pathologic study of 105 cases involving oral cavity, larynx and genitalia. Cancer 1966;19:26–38. 2. Miyamoto T, Sasaoka R, Hagari Y, Mihara M. Association of cutaneous verrucous carcinoma with human papillomavirus type 16. Br J Dermatol 1999;140:168–9.
* Corresponding author. Pei-Shan Yen. E-mail: P.-S. Yen