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Verrucous carcinoma of the back
Volume 14 Number 5, Part 2 May, 1986
Bullous pemphigoid and prurigo nodularis
ilesional skin may be useful in patients with prurigo nodularis, especially in those patients who subsequently develop bullae.
6. 7.
REFERENCES 1. Lever WF: Pemphigus and pemphigoid: A review of the advances made since 1964. J AM ACADDERMATOL1:231, 1979. 2. Jorizzo JL, Gatti S, Smith EB: Prurigo: A clinical review. J AM ACADDERMATOL4:723-728, 1981. 3. Doyle JA, Connolly SM, Hunziker N, et al: Prurigo nodularis: A reappraisal of the clinical and histologic features. J Cutan Pathol 6:392-403, 1979. 4. Yung CW, Soltani K, Lorincz AL: Pemphigoid nodularis. J AM ACAD DE~tMATOL5:54-60, 198 1. 5. Massa MC, Connolly SM: Bullous pemphigoid with lea-
Ill
8. 9. I0. 11.
tures of prurigo nodularis. Arch Dermatol 118:937-939, 1982. Provost TT, Maize JC, Ahmed AR, et al: Unusual subepidermal bullous diseases with immunologic features pemphigoid. Arch Dermatol 115:156-160, 1979. Person JR, Rogers RS III, Perry HO: Localized pemphigoid. Br J Dermatol 95"531-534, 1976. Honeyman JF, Honeyman AR, De la Parra MA, ct al: Polymorphic pemphigoid. Arch Derrnatol 115:423-437, 1979. Bean SF, Michel B, Fury N, et al: Vesicular pemphigoid. Arch Derm atol 112:1402-1406, 1976. Winkelmann RK, Su WP: Pemphigoid vegetans. Arch Dermatol 115:446-448, 1979. Person JR, Rogers RS: Bullous and cicatricial pemphigoid: Clinical histopathologic and immunopathologic correlations. Mayo Clin Proc 52:54-66, 1977.
II
Verrucous carcinoma of the back Evaristo Sanchez-Yus, M.D., Estrella Velasco, M.D., and Alfredo Robledo, M.D.
Madrid, Spain A case of verrucous carcinoma occurring on the dorsolu,nbar region of the back is reported. Verrucous carcinoma, although usually appearing on three leading sites (pan-oral, genitogluteal, and plantar), can exceptionally arise anywhere on the skin surface. It is important to be aware of this fact for more accurate diagnosis and treatment. (J AM ACAD DERMATOL14:947-50, 1986.)
Verrucous carcinoma is a low-grade squamous cell carcinoma first described by Ackerman ~in the oral cavity. It is a slowly growing tumor that extends in surface area and locally invades contiguous structures. Some cases even destroy a considerable portion of the mandible, but verrucous carcinoma only rarely metastasizes. Similar cases have also been recorded under the term oralflorid papillornatosis. Verrucous carcinoma also occurs on the anogenital region, where it formerly was termed giant condyloma acuminatum of Buschke and Lrwenstein. A third localization of this tumor is the plantar surface, where it also receives the name carcinoma cuniculatum on the basis of its From the Departamento de Dermatologia, Hospital Clinico de la Facultad de Medicina, Universidad Complutense. Reprint requests to: Dr. E. Sanchez-Yus, Departarnento de Dermatologia, Hospital Clinlco, Ciudad Universitaria, 28040 Madrid, Spain.
numerous crypts and sinuses, which resemble rabbit burrows. Mohs and Sahl z have proposed the adjectives pan-oral, genitogluteal, and plantar for designating these three leading forms o f verrucous carcinoma, all of them occurring in areas of maceration (Table I). Exceptionally, verrucous carcinomas have been reported to arise on the hand (four cases), *'~'4 lower portion of the leg (three cases), 3'5'6 kr~ee (one case), 4 face (two cases), 4'7 and shoulder (one case): Here we report a case of giant verrucous carcinoma arising on the dorsolumbar region of the back. Thus verrucous carcinoma, although appearing usually on three principal sites, can probably sprout anywhere on the skin surface. *Vilanova X, Cabr6 J: Pseudoepitelioma(Aztia): Papilomatosis cuffs carcinoides (Gottron). Actas Dermosifilogr (Madrid) 55:753-762, 1964.
947
948
Journal of the American Academy of Dermatology
Sanchez-Yus et al
T a b l e I. Classification o f verrucous carcinoma
(Mohs and Sahl 2) Proposed titles
Areas involved
Previous titles
Pan-oral verrucous Oral cavity Oral florid papilcarcinoma Nasal cavity lomatosis Larynx Esophagus Genitogluteal ver- Penis Giant condyloma rucous carciScrotum acuminatum noma Vulva (Buschke and Anus Lrwenstein) Rectum Vagina Cervix Buttocks Plantar verrucous Plantar surface Epithelioma carcinoma cuniculatum Fig. 1. Fungating mass on the right dorsolumbar region of the back. CASE R E P O R T A 64-year-old man was referred to the hospital because of an extensive, fungating mass on the right dorsolumbar region of the back. Four years earlier he had noted a little " g r a i n " on that site. This lesion gradually enlarged and spread. It was painless and malodorous, and it sometimes bled slightly when touched. Examination showed an exophytic, fungating, papillomatous, foul-smelling tumor measuring 10 x 8 x 3 cm and partly covered with a yellowish brown crust (Fig. 1). Physical examination revealed lung emphysema with lung arterial hypertension and a mild, chronic peripheral neuropathy caused by alcoholism. No palpable lymph node was detected. Two biopsies were taken, and both showed a proliferation of well-differentiated squamous epithelium composed of broad strands. The cells possessed a large, eosinophilic cytoplasm and differentiated toward laminated parakeratotic keratin. Sometimes the strands joined in a keratin-filled crater. Some dyskeratoses were present, but there was no significant nuclear atypia. The lesion was considered to be a low-grade squamous cell carcinoma. With the patient under general anesthesia, the tumor was excised with a 2- to 5-cm margin exposing the underlying fascia. The wound was covered by a splitthickness skin graft. Gross examination of the surgical specimen clearly showed the papillomatous pattern of the tumor, which seemed to invade the dermis to its full thickness. Microscopic examination revealed a structural and cytologic picture similar to that of previous biopsies (Fig. 2). Frequently the parakeratotic
horn pearls were surrounded by various layers of granular ceils. The epithelial strands infiltrated the dermis to its full thickness but did not invade the subcutaneous fat. There were no intraepithelial microabscesses, but a diffuse infiltrate composed largely of neutrophils sometimes obscured the tips of the papillary projections. The deepest tumoral nodules were surrounded by a dense inflammatory reaction largely formed by lymphoid cells, plasma cells, and some eosinophils (Fig. 3). The subcutaneous fat was fibrosed and scattered by some lymph follicles. In veiw of the clinical, macroscopic, and microscopic features, the tumor was interpreted as a verrucous carcinoma. DISCUSSION Various etiologic factors have been claimed for verrucous carcinoma. T h e use o f chewing tobacco has been considered significantly related to the development of verrucous carcinoma o f the oral cavity by a number of authors, including Ackerman, 1'9t~ but Elliot et al 5 considered such an association to be variable and coincidental. A possible viral cause has been considered for plantar and genitogluteal cases, where a close relationship with plantar warts and condylomata acuminata has frequently been suggested. 12-~4 Electron microscopy and immunoperoxidase studies have not at present confirmed those suspicions, 3.~5"t7 but human papillomavirus deoxyribonucleic acid has been identified by way o f hybridization studies in two cases of anogenital verrucous carcinoma, ts Finally, Klima et al6 concluded that " a preced-
Volume 14 Number 5, Part 2 May, 1986
Fig. 2. Keratin-filled crypts formed by confluence of epithelial nodules and strands. These are formed by a well-differentiated squamous epithelium. Some nodules are centered by granular cells. (Hematoxylin-eosin stain; x 20.) ing chronic infection is an important factor in the pathogenesis of these tumors." Microscopic diagnosis of verrucous carcinoma is usually a difficult problem, largely as a result of its cellular benignity. We agree with Brodin and Mehregan ~9that a marked nuclear atypia is incompatible with the diagnosis of verrucous carcinoma. Consequently the differential diagnosis of verrucous carcinoma includes mainly viral warts and condylomata acuminata, keratoacanthoma, and pseudocarcinomatous hyperplasia. It is not the cytologic details but the clinical, macroscopic, and architectural features that will provide us with the key to diagnosis. Verrucous carcinoma is a sharply demarcated, exophytic, papillomatous growth that enlarges progressively through the years, not infrequently reaching a diameter of 5 cm or more. At low magnification, verrucous carcinoma shows an exophytic and endophytic proliferation in a zigzag, s or accordion-like, pattern. 6 These rete ridges have a
Verrucous carcinoma
949
Fig. 3. A deep tumoral nodule surrounded by a dense inflammatory reaction largely formed by lymphoid and plasma cells. (Hematoxylin-eosin stain; x 200.) bulbous appearence and are composed of large, well-differentiated squamous epithelial ceils. After a variable period of surface extension, verrucous carcinoma may invade and destroy subjacent structures, but lymph node metastases are exceptional, even in the mucosal cases. When confronted with bony structures, the tumor erodes rather than infiltrates. On the contrary, keratoacanthoma is never verrucous in appearance and has a self-limited, selfhealing course. Structurally its multilocular crater of multifollicular origin clearly stands out. Viral warts and condylomata acuminata do not have an endophytic growth phase and show clumped keratohyaline granules and/or vacuolization in the granular and/or upper spinous layers. Electron microscopy2~and immunoperoxidase studies 2' frequently detect the papovavirus. These lesions respond to adequate therapy and do not usually persist for many years, having a tendency toward spontaneous regression. Pseudocarcinomatous hyperplasia is a reactive process to a precipitating or associated factor,
950
Sanchez-Yus et al
has a limited growth, and m a y regress when its cause disappears. Furthermore, the proliferation is more often downward and the rete ridges are uneven, sharply pointed, and jagged. Not infrequently, atypia and prominent mitotic activity are present.6'22 Ackermaff proposed radiation for the treatment of small, superficial lesions and radical surgery for extensive ones. Kraus and P6rez-Mesa, t~ in a series of 105 cases, found an excellent result in the eighty-eight patients surgically treated; radiation therapy, applied to seventeen patients, failed to control the lesion in all instances. Moreover, in four of these patients the tumor underwent an anaplastic transformation, metastases appeared, and all the patients died a few months later. Schwade et al,'-~ on the basis of their own experience and a review of the literature, concluded that radiotherapy is not less effective than surgery in controlling or curing verrucous carcinoma and that the former does not cause increased invasiveness or anaplastie transformation. Other conservative therapies such as Mobs' chemosurgery ~-.~6,24'2~and carbon dioxide laser, 26 have been advocated. In our case a giant verrucous carcinoma developed on the normal skin of the back. This unusual localization rendered an appropriate diagnosis difficult and precluded consideration of a more conservative therapy. Verrucous carcinoma is no doubt a distinctive anatomicoclinical entity be be envisaged in the differential diagnosis of all long-lived, mature squamous cell verrucous lesions, whatever their localization. Verrucous carcinoma, as a locally destructive growth that only rarely metastasizes, may perhaps be regarded as the squamous cell counterpart of basal cell carcinoma. REFERENCES
1. Aekerman LV: Verrucous carcinoma of the oral cavity. Surgery 23:670-678, 1948. 2. Mohs FE, SahI WJ: Chemosurgery for verrucous carcinoma. J Dermatol Surg Oncol 5:302-306, 1979. 3. Kao GF, Graham JH, Helwig EB: Carcinoma cuniculatum (verrucous carcinoma of the skin): A clinicopathologic study of 46 cases with ultrastn~ctural observations. Cancer 49:2395-2403, 1982. 6. Wilkinson JD, Black MM: Carcinoma cunieulatum: A clinieopathologic study of 21 cases. Arch Dermatol 116:1390, 1980.
Journal of the American Academy of Dermatology
5. Elliot GB, MacDougall JA, Elliot JDA: Problems of vcrmcous carcinoma. Arm Surg 177:21-29, 1973. 6. Klima M, Kurtis B, Jordon PH Jr: Verrucous carcinoma of skin. J Cutan Pathol 7:88-98, 1980. 7. Nguyen KO, McMarlin SL: Verrucous carcinoma of the face. Arch Dcrmatol 120:383-385, 1984. 8. Greenberg SD, Wallace SA: Giant cutaneous papilloma of the shoulder. Arch Pathol 76:446-448, 1963. 9. Sorger K, Myrden JA: Verrucous carcinoma of the buccal mucosa in tobacco chewers. Can Med Assoc J 83:14131417, 1960. 10. Stecker RH, Devine DD, Harrison EG: Verrucous "snuff dippers" carcinoma of the oral cavity: A case of selfinduced carcinogenesis. JAMA 189:838-840, 1964. 11. Kraus FF, P&ez-Mesa C: Verrucous carcinoma: Clinical and pathologic study of 105 cases involving oral cavity, larynx and genitalia. Cancer 19:26-39, 1966. 12. Wilkinson JD, MeKee PH, Black MM, et al; A case of carcinoma cuniculatum with coexistent viral phmtar wart. Clin Exp Dermatol 6:619-623, 1981. 13. Fi]dstcin MS, Bucker WC, Payne CM, ct at: Observation of virus-like particles in a carcinoma of the penis. Ariz Meal 33:450-453, 1976. 14. Lynch PJ: Warts and cancer: The oncogenie potential of human papilloma virus. Am J Dermatopathol 4:55-58, 1982. 15. Farmer ER, Braun L, Shah KV: Immunologic staining for human papillomavirus in cutaneous displasia. Arch Dermatol 116:1389, 1980, 16. Swanson NA, Taylor WB: Plantar verrucous carcinoma: Literature review and treatment by Mohs' chemosurgery technique. Arch Dermatol 116:794-797, 1980. 17. McKee PH, Wilkinson JD, Black MM, et al: Carcinoma (epithelioma) cuniculatum: A clinico-pathological study of nineteen cases and review of the literature. Histopathology 5:425-436, 1981. 18. Ubben K, Krzyzek R, Ostrow R, et al: Human papillomavirus DNA detected in two vermcous carcinomas. J Invest Dermatol 72:195, 1979. 19. Brodin MB, Mehregan AH: Verrucous carcinoma. Arch Dermatol 116:987, 1980. 20. Barrera-Oro JG: Quantitation of papovavirus particles in human warts. JNCI 29:583-596, 1962. 21. Penneys NS, Mogollon RJ, Nadj M, et al: Papillomavirus common antigens: Papillomavims antigen in verruca, benign papillomatous lesions, trichilemmoma and bowenoid papulosis: An immunopcroxidase study. Arch Dermatol 120:859-861, 1984. 22. Lever WF, Schaumburg-Lever G: Histopathology of the skin, ed. 6. Philadelphia, 1983, J. B, Lippincott Co., p. 505. 23. Schwade JG, Wara WN, Dedo HH, et al: Radiotherapy for verrucous carcinoma. Radiology 120:677-679, 1976. 24. Morn RG: Microscopicaly controlled surgery (Mobs' chemosurgery) for treatment of verrucous squamous cell carcinoma of the foot (epithelioma cuniculatum). J AM Acao DERMATOU8:354-362, 1983. 25. Hanke CW, Bailin PL, O'Brian JJ: Chemosurgical reports: Plantar verrucous carcinoma in black women. J Dermatol Surg Oncol 10:90-93, 1984. 26. Persky M: Carbon dioxide laser treatment of oral florid papillomatosis. J Dermatol Surg Oncol 10:64-66, 1984.
Bullous pemphigoid and prurigo nodularis
ilesional skin may be useful in patients with prurigo nodularis, especially in those patients who subsequently develop bullae.
6. 7.
REFERENCES 1. Lever WF: Pemphigus and pemphigoid: A review of the advances made since 1964. J AM ACADDERMATOL1:231, 1979. 2. Jorizzo JL, Gatti S, Smith EB: Prurigo: A clinical review. J AM ACADDERMATOL4:723-728, 1981. 3. Doyle JA, Connolly SM, Hunziker N, et al: Prurigo nodularis: A reappraisal of the clinical and histologic features. J Cutan Pathol 6:392-403, 1979. 4. Yung CW, Soltani K, Lorincz AL: Pemphigoid nodularis. J AM ACAD DE~tMATOL5:54-60, 198 1. 5. Massa MC, Connolly SM: Bullous pemphigoid with lea-
Ill
8. 9. I0. 11.
tures of prurigo nodularis. Arch Dermatol 118:937-939, 1982. Provost TT, Maize JC, Ahmed AR, et al: Unusual subepidermal bullous diseases with immunologic features pemphigoid. Arch Dermatol 115:156-160, 1979. Person JR, Rogers RS III, Perry HO: Localized pemphigoid. Br J Dermatol 95"531-534, 1976. Honeyman JF, Honeyman AR, De la Parra MA, ct al: Polymorphic pemphigoid. Arch Derrnatol 115:423-437, 1979. Bean SF, Michel B, Fury N, et al: Vesicular pemphigoid. Arch Derm atol 112:1402-1406, 1976. Winkelmann RK, Su WP: Pemphigoid vegetans. Arch Dermatol 115:446-448, 1979. Person JR, Rogers RS: Bullous and cicatricial pemphigoid: Clinical histopathologic and immunopathologic correlations. Mayo Clin Proc 52:54-66, 1977.
II
Verrucous carcinoma of the back Evaristo Sanchez-Yus, M.D., Estrella Velasco, M.D., and Alfredo Robledo, M.D.
Madrid, Spain A case of verrucous carcinoma occurring on the dorsolu,nbar region of the back is reported. Verrucous carcinoma, although usually appearing on three leading sites (pan-oral, genitogluteal, and plantar), can exceptionally arise anywhere on the skin surface. It is important to be aware of this fact for more accurate diagnosis and treatment. (J AM ACAD DERMATOL14:947-50, 1986.)
Verrucous carcinoma is a low-grade squamous cell carcinoma first described by Ackerman ~in the oral cavity. It is a slowly growing tumor that extends in surface area and locally invades contiguous structures. Some cases even destroy a considerable portion of the mandible, but verrucous carcinoma only rarely metastasizes. Similar cases have also been recorded under the term oralflorid papillornatosis. Verrucous carcinoma also occurs on the anogenital region, where it formerly was termed giant condyloma acuminatum of Buschke and Lrwenstein. A third localization of this tumor is the plantar surface, where it also receives the name carcinoma cuniculatum on the basis of its From the Departamento de Dermatologia, Hospital Clinico de la Facultad de Medicina, Universidad Complutense. Reprint requests to: Dr. E. Sanchez-Yus, Departarnento de Dermatologia, Hospital Clinlco, Ciudad Universitaria, 28040 Madrid, Spain.
numerous crypts and sinuses, which resemble rabbit burrows. Mohs and Sahl z have proposed the adjectives pan-oral, genitogluteal, and plantar for designating these three leading forms o f verrucous carcinoma, all of them occurring in areas of maceration (Table I). Exceptionally, verrucous carcinomas have been reported to arise on the hand (four cases), *'~'4 lower portion of the leg (three cases), 3'5'6 kr~ee (one case), 4 face (two cases), 4'7 and shoulder (one case): Here we report a case of giant verrucous carcinoma arising on the dorsolumbar region of the back. Thus verrucous carcinoma, although appearing usually on three principal sites, can probably sprout anywhere on the skin surface. *Vilanova X, Cabr6 J: Pseudoepitelioma(Aztia): Papilomatosis cuffs carcinoides (Gottron). Actas Dermosifilogr (Madrid) 55:753-762, 1964.
947
948
Journal of the American Academy of Dermatology
Sanchez-Yus et al
T a b l e I. Classification o f verrucous carcinoma
(Mohs and Sahl 2) Proposed titles
Areas involved
Previous titles
Pan-oral verrucous Oral cavity Oral florid papilcarcinoma Nasal cavity lomatosis Larynx Esophagus Genitogluteal ver- Penis Giant condyloma rucous carciScrotum acuminatum noma Vulva (Buschke and Anus Lrwenstein) Rectum Vagina Cervix Buttocks Plantar verrucous Plantar surface Epithelioma carcinoma cuniculatum Fig. 1. Fungating mass on the right dorsolumbar region of the back. CASE R E P O R T A 64-year-old man was referred to the hospital because of an extensive, fungating mass on the right dorsolumbar region of the back. Four years earlier he had noted a little " g r a i n " on that site. This lesion gradually enlarged and spread. It was painless and malodorous, and it sometimes bled slightly when touched. Examination showed an exophytic, fungating, papillomatous, foul-smelling tumor measuring 10 x 8 x 3 cm and partly covered with a yellowish brown crust (Fig. 1). Physical examination revealed lung emphysema with lung arterial hypertension and a mild, chronic peripheral neuropathy caused by alcoholism. No palpable lymph node was detected. Two biopsies were taken, and both showed a proliferation of well-differentiated squamous epithelium composed of broad strands. The cells possessed a large, eosinophilic cytoplasm and differentiated toward laminated parakeratotic keratin. Sometimes the strands joined in a keratin-filled crater. Some dyskeratoses were present, but there was no significant nuclear atypia. The lesion was considered to be a low-grade squamous cell carcinoma. With the patient under general anesthesia, the tumor was excised with a 2- to 5-cm margin exposing the underlying fascia. The wound was covered by a splitthickness skin graft. Gross examination of the surgical specimen clearly showed the papillomatous pattern of the tumor, which seemed to invade the dermis to its full thickness. Microscopic examination revealed a structural and cytologic picture similar to that of previous biopsies (Fig. 2). Frequently the parakeratotic
horn pearls were surrounded by various layers of granular ceils. The epithelial strands infiltrated the dermis to its full thickness but did not invade the subcutaneous fat. There were no intraepithelial microabscesses, but a diffuse infiltrate composed largely of neutrophils sometimes obscured the tips of the papillary projections. The deepest tumoral nodules were surrounded by a dense inflammatory reaction largely formed by lymphoid cells, plasma cells, and some eosinophils (Fig. 3). The subcutaneous fat was fibrosed and scattered by some lymph follicles. In veiw of the clinical, macroscopic, and microscopic features, the tumor was interpreted as a verrucous carcinoma. DISCUSSION Various etiologic factors have been claimed for verrucous carcinoma. T h e use o f chewing tobacco has been considered significantly related to the development of verrucous carcinoma o f the oral cavity by a number of authors, including Ackerman, 1'9t~ but Elliot et al 5 considered such an association to be variable and coincidental. A possible viral cause has been considered for plantar and genitogluteal cases, where a close relationship with plantar warts and condylomata acuminata has frequently been suggested. 12-~4 Electron microscopy and immunoperoxidase studies have not at present confirmed those suspicions, 3.~5"t7 but human papillomavirus deoxyribonucleic acid has been identified by way o f hybridization studies in two cases of anogenital verrucous carcinoma, ts Finally, Klima et al6 concluded that " a preced-
Volume 14 Number 5, Part 2 May, 1986
Fig. 2. Keratin-filled crypts formed by confluence of epithelial nodules and strands. These are formed by a well-differentiated squamous epithelium. Some nodules are centered by granular cells. (Hematoxylin-eosin stain; x 20.) ing chronic infection is an important factor in the pathogenesis of these tumors." Microscopic diagnosis of verrucous carcinoma is usually a difficult problem, largely as a result of its cellular benignity. We agree with Brodin and Mehregan ~9that a marked nuclear atypia is incompatible with the diagnosis of verrucous carcinoma. Consequently the differential diagnosis of verrucous carcinoma includes mainly viral warts and condylomata acuminata, keratoacanthoma, and pseudocarcinomatous hyperplasia. It is not the cytologic details but the clinical, macroscopic, and architectural features that will provide us with the key to diagnosis. Verrucous carcinoma is a sharply demarcated, exophytic, papillomatous growth that enlarges progressively through the years, not infrequently reaching a diameter of 5 cm or more. At low magnification, verrucous carcinoma shows an exophytic and endophytic proliferation in a zigzag, s or accordion-like, pattern. 6 These rete ridges have a
Verrucous carcinoma
949
Fig. 3. A deep tumoral nodule surrounded by a dense inflammatory reaction largely formed by lymphoid and plasma cells. (Hematoxylin-eosin stain; x 200.) bulbous appearence and are composed of large, well-differentiated squamous epithelial ceils. After a variable period of surface extension, verrucous carcinoma may invade and destroy subjacent structures, but lymph node metastases are exceptional, even in the mucosal cases. When confronted with bony structures, the tumor erodes rather than infiltrates. On the contrary, keratoacanthoma is never verrucous in appearance and has a self-limited, selfhealing course. Structurally its multilocular crater of multifollicular origin clearly stands out. Viral warts and condylomata acuminata do not have an endophytic growth phase and show clumped keratohyaline granules and/or vacuolization in the granular and/or upper spinous layers. Electron microscopy2~and immunoperoxidase studies 2' frequently detect the papovavirus. These lesions respond to adequate therapy and do not usually persist for many years, having a tendency toward spontaneous regression. Pseudocarcinomatous hyperplasia is a reactive process to a precipitating or associated factor,
950
Sanchez-Yus et al
has a limited growth, and m a y regress when its cause disappears. Furthermore, the proliferation is more often downward and the rete ridges are uneven, sharply pointed, and jagged. Not infrequently, atypia and prominent mitotic activity are present.6'22 Ackermaff proposed radiation for the treatment of small, superficial lesions and radical surgery for extensive ones. Kraus and P6rez-Mesa, t~ in a series of 105 cases, found an excellent result in the eighty-eight patients surgically treated; radiation therapy, applied to seventeen patients, failed to control the lesion in all instances. Moreover, in four of these patients the tumor underwent an anaplastic transformation, metastases appeared, and all the patients died a few months later. Schwade et al,'-~ on the basis of their own experience and a review of the literature, concluded that radiotherapy is not less effective than surgery in controlling or curing verrucous carcinoma and that the former does not cause increased invasiveness or anaplastie transformation. Other conservative therapies such as Mobs' chemosurgery ~-.~6,24'2~and carbon dioxide laser, 26 have been advocated. In our case a giant verrucous carcinoma developed on the normal skin of the back. This unusual localization rendered an appropriate diagnosis difficult and precluded consideration of a more conservative therapy. Verrucous carcinoma is no doubt a distinctive anatomicoclinical entity be be envisaged in the differential diagnosis of all long-lived, mature squamous cell verrucous lesions, whatever their localization. Verrucous carcinoma, as a locally destructive growth that only rarely metastasizes, may perhaps be regarded as the squamous cell counterpart of basal cell carcinoma. REFERENCES
1. Aekerman LV: Verrucous carcinoma of the oral cavity. Surgery 23:670-678, 1948. 2. Mohs FE, SahI WJ: Chemosurgery for verrucous carcinoma. J Dermatol Surg Oncol 5:302-306, 1979. 3. Kao GF, Graham JH, Helwig EB: Carcinoma cuniculatum (verrucous carcinoma of the skin): A clinicopathologic study of 46 cases with ultrastn~ctural observations. Cancer 49:2395-2403, 1982. 6. Wilkinson JD, Black MM: Carcinoma cunieulatum: A clinieopathologic study of 21 cases. Arch Dermatol 116:1390, 1980.
Journal of the American Academy of Dermatology
5. Elliot GB, MacDougall JA, Elliot JDA: Problems of vcrmcous carcinoma. Arm Surg 177:21-29, 1973. 6. Klima M, Kurtis B, Jordon PH Jr: Verrucous carcinoma of skin. J Cutan Pathol 7:88-98, 1980. 7. Nguyen KO, McMarlin SL: Verrucous carcinoma of the face. Arch Dcrmatol 120:383-385, 1984. 8. Greenberg SD, Wallace SA: Giant cutaneous papilloma of the shoulder. Arch Pathol 76:446-448, 1963. 9. Sorger K, Myrden JA: Verrucous carcinoma of the buccal mucosa in tobacco chewers. Can Med Assoc J 83:14131417, 1960. 10. Stecker RH, Devine DD, Harrison EG: Verrucous "snuff dippers" carcinoma of the oral cavity: A case of selfinduced carcinogenesis. JAMA 189:838-840, 1964. 11. Kraus FF, P&ez-Mesa C: Verrucous carcinoma: Clinical and pathologic study of 105 cases involving oral cavity, larynx and genitalia. Cancer 19:26-39, 1966. 12. Wilkinson JD, MeKee PH, Black MM, et al; A case of carcinoma cuniculatum with coexistent viral phmtar wart. Clin Exp Dermatol 6:619-623, 1981. 13. Fi]dstcin MS, Bucker WC, Payne CM, ct at: Observation of virus-like particles in a carcinoma of the penis. Ariz Meal 33:450-453, 1976. 14. Lynch PJ: Warts and cancer: The oncogenie potential of human papilloma virus. Am J Dermatopathol 4:55-58, 1982. 15. Farmer ER, Braun L, Shah KV: Immunologic staining for human papillomavirus in cutaneous displasia. Arch Dermatol 116:1389, 1980, 16. Swanson NA, Taylor WB: Plantar verrucous carcinoma: Literature review and treatment by Mohs' chemosurgery technique. Arch Dermatol 116:794-797, 1980. 17. McKee PH, Wilkinson JD, Black MM, et al: Carcinoma (epithelioma) cuniculatum: A clinico-pathological study of nineteen cases and review of the literature. Histopathology 5:425-436, 1981. 18. Ubben K, Krzyzek R, Ostrow R, et al: Human papillomavirus DNA detected in two vermcous carcinomas. J Invest Dermatol 72:195, 1979. 19. Brodin MB, Mehregan AH: Verrucous carcinoma. Arch Dermatol 116:987, 1980. 20. Barrera-Oro JG: Quantitation of papovavirus particles in human warts. JNCI 29:583-596, 1962. 21. Penneys NS, Mogollon RJ, Nadj M, et al: Papillomavirus common antigens: Papillomavims antigen in verruca, benign papillomatous lesions, trichilemmoma and bowenoid papulosis: An immunopcroxidase study. Arch Dermatol 120:859-861, 1984. 22. Lever WF, Schaumburg-Lever G: Histopathology of the skin, ed. 6. Philadelphia, 1983, J. B, Lippincott Co., p. 505. 23. Schwade JG, Wara WN, Dedo HH, et al: Radiotherapy for verrucous carcinoma. Radiology 120:677-679, 1976. 24. Morn RG: Microscopicaly controlled surgery (Mobs' chemosurgery) for treatment of verrucous squamous cell carcinoma of the foot (epithelioma cuniculatum). J AM Acao DERMATOU8:354-362, 1983. 25. Hanke CW, Bailin PL, O'Brian JJ: Chemosurgical reports: Plantar verrucous carcinoma in black women. J Dermatol Surg Oncol 10:90-93, 1984. 26. Persky M: Carbon dioxide laser treatment of oral florid papillomatosis. J Dermatol Surg Oncol 10:64-66, 1984.