Verrucous Squamous Cell Carcinoma of Skin

Verrucous Squamous Cell Carcinoma of Skin

Article
Skin Care
Diseases & Conditions
+1
Contributed byLester Fahrner, MD+1 moreMay 21, 2021

What are the other Names for this Condition? (Also known as/Synonyms)

  • Ackerman’s Tumor
  • Cutaneous Verrucous Squamous Cell Carcinoma
  • Oral Florid Papillomatosis

What is Verrucous Squamous Cell Carcinoma of Skin? (Definition/Background Information)

  • Verrucous Squamous Cell Carcinoma of Skin is a malignant tumor of skin that typically affects elderly men and women. It has a lower metastatic potential than conventional squamous cell carcinomas. The verrucous form is a rare subtype of squamous cell carcinoma (SCC) with a slower growth. It constitutes approximately 5% of all SCCs of skin
  • The cause of Verrucous Squamous Cell Carcinoma of Skin is unknown, but genetic mutations may be involved. Factors that may influence its development include poor oral hygiene, fungal infections affecting the skin, and lichen planus
  • Verrucous Squamous Cell Carcinoma of Skin may appear as warty tumors of the skin, seen most commonly on the soles of the feet, anogenital areas, and oral mucosa. The lesions may ulcerate and cause scarring of skin
  • The treatment of choice is Mohs micrographic surgery performed until clear margins are obtained, followed by radiation therapy or chemotherapy, as decided by the healthcare provider. In majority of the cases, the prognosis is excellent with appropriate treatment. There are sometimes concerns that radiation can transform the carcinoma to a more aggressive form
  • Mohs micrographic surgery may be difficult on intraoral lesions, in which case, a wide surgical excision is performed. The same is true for extremely large tumors on the extremities and genital area lesions
  • Nevertheless, the prognosis of Verrucous Squamous Cell Carcinoma of Skin depends upon many factors including the stage of the tumor and health status of the affected individual. There is a possibility of local or regional metastasis, which can involve the lymph nodes. This may dictate the course of the condition

Who gets Verrucous Squamous Cell Carcinoma of Skin? (Age and Sex Distribution)

  • Verrucous Squamous Cell Carcinoma of Skin is a rare condition that generally affects elderly or older adults; some cases develop in children too, though infrequently
  • It can occur in both males and females; however, males are affected more than females
  • Squamous cell carcinoma of skin is prevalent worldwide, though dark-skinned individuals (Asians and Africans) are affected less than lighter-skinned individuals (Europeans and Americans)

What are the Risk Factors for Verrucous Squamous Cell Carcinoma of Skin? (Predisposing Factors)

The risk factors for Verrucous Squamous Cell Carcinoma of Skin include:

  • Chronic irritation of skin
  • Oral lesions due to decaying teeth, poor oral hygiene, and poorly-fitting dentures, among other factors
  • Tobacco chewing
  • Human papilloma virus (HPV) infection
  • Lichen planus
  • Skin fungal infections
  • Individuals with weak immune system, which could be due to cancer treatment, AIDS, or those on immunosuppressant drugs after receiving an organ transplant

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one's chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Verrucous Squamous Cell Carcinoma of Skin? (Etiology)

  • Currently, the cause of formation of Verrucous Squamous Cell Carcinoma of Skin is unknown
  • However, genetic mutations have been detected, which are currently being characterized

What are the Signs and Symptoms of Verrucous Squamous Cell Carcinoma of Skin?

The signs and symptoms of Verrucous Squamous Cell Carcinoma of Skin include:

  • In a majority of cases, cutaneous SCC is asymptomatic and does not present any signs or symptoms during the initial period
  • The tumors are generally slower growing in comparison to conventional SCCs
  • The tumor may be single; though, it is not uncommon to find multiple tumors in an individual
  • Formation of skin lesions that are well-differentiated and appear as warts
  • These nodules are common in the arms and legs (extremities), genital areas, and mouth (oral mucosa). It is uncommon in the vagina and perianal skin
  • It may ulcerate and bleed. Occasionally, after the ulcer heals, it may become ulcerated again
  • Discomfort and irritability of the affected skin may be noted
  • The size of the lesions range from 1-10 cm; average size is usually less than 3 cm
  • In some cases, the squamous cell carcinoma may appear more pigmented than surrounding skin
  • Individuals with immunocompromised states have more aggressive tumors

How is Verrucous Squamous Cell Carcinoma of Skin Diagnosed?

A diagnosis of Verrucous Squamous Cell Carcinoma of Skin is made using the following tests and exams:

  • Complete physical examination with detailed medical history evaluation
  • Examination by a dermatologist using a dermoscopy, a special device to examine the skin
  • Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation

Although the above modalities can be used to make an initial diagnosis, a tissue biopsy of the tumor is necessary to make a definitive diagnosis to begin treatment.

Tissue biopsy:

  • A tissue biopsy of the tumor is performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis. Examination of the biopsy under a microscope by a pathologist is considered to be gold standard in arriving at a conclusive diagnosis
  • Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The pathologist then decides on additional studies depending on the clinical situation
  • Sometimes, the pathologist may perform special studies, which may include immunohistochemical stains, molecular testing, and very rarely, electron microscopic studies to assist in the diagnosis

In case of metastatic SCC, the following diagnostic procedures can be used to procure the tissue sample:

  • Fine needle aspiration (FNA) biopsy of the tumor: A FNA biopsy may not be helpful, because one may not be able to visualize the different morphological areas of the tumor. Hence, a FNA biopsy as a diagnostic tool has certain limitations, and an open surgical biopsy is preferred
  • Core biopsy or open biopsy of the tumor: Generally, these methods are not suited or preferred

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Verrucous Squamous Cell Carcinoma of Skin?

The possible complications due to Verrucous Squamous Cell Carcinoma of Skin include:

  • Discomfort, irritability of the affected skin
  • Large lesions may ulcerate and bleed resulting in superimposed bacterial or fungal infections
  • Permanent scarring might occur with SCC and cosmetic surgery may be required to restore the skin condition
  • They can metastasize to the lymph nodes
  • Tumors that invade into nerves (perineurial invasion) have higher chances of recurrence and metastasis
  • In general, squamous cell carcinoma of skin in certain locations has higher chances of metastasis and they include:
    • On the lips
    • On the penile skin
    • In the region of radiation scar
    • In the region of scar due to burns
    • Vulvar skin
    • Perianal skin
  • Tumors that are over 2 cm in size have a higher incidence of recurrence and metastasis, than tumors that are less than 2 cm in size

Typically, Verrucous SCC of Skin is not as aggressive as conventional SCCs and has a lower metastatic potential.

How is Verrucous Squamous Cell Carcinoma of Skin Treated?

Early diagnosis and treatment of Verrucous Squamous Cell Carcinoma of Skin is important to avoid complications such as metastasis to other regions, as well as morbidity from treatments needed for large lesions.

The treatment measures for the condition may include:

  • In many cases, a wide surgical excision and removal of the entire tumor is the preferred treatment option. This may be followed by radiation therapy and/or chemotherapy
  • Mohs micrographic surgery is often the optimal treatment method
  • If the tumor has metastasized (in rare cases), then a combination of chemotherapy, radiation therapy, and invasive procedures may be used to treat the tumor
  • Targeted therapy medications are generally used for locally infiltrated or metastatic SCCs. This therapy destroys the tumor cells by acting against the proteins that are responsible for tumor growth. FDA-approved medications include cemiplimab and pembrolizumab
  • Large tumors after complete skin excision may need skin grafting or a flap to repair the defect
  • Treatment of the underlying condition (if any present)
  • Post-operative care is important until the surgical wound heals

Follow-up care with regular screening and check-ups are important and encouraged.

How can Verrucous Squamous Cell Carcinoma of Skin be Prevented?

A few methods to prevent Verrucous Squamous Cell Carcinoma of Skin include:

  • Maintaining proper oral hygiene
  • Avoiding chewing tobacco and smoking

Regular medical screening at periodic intervals with blood tests, scans, and physical examinations, are mandatory, due to its metastasizing potential and possibility of recurrence. Often several years of active vigilance is necessary.

What is the Prognosis of Verrucous Squamous Cell Carcinoma of Skin? (Outcomes/Resolutions)

  • In general, Verrucous Squamous Cell Carcinoma of Skin is a form of skin cancer that can be treated with complete excisional surgery. Tumors in their early stage on complete excision typically have an excellent prognosis
  • In cases of metastasis, its prognosis depends upon a set of several factors that include:
    • Stage of tumor: With lower-stage tumors, when the tumor is confined to site of origin, the prognosis is usually excellent with appropriate therapy. In higher-stage tumors, such as tumors with metastasis, the prognosis is poor
    • The surgical resectability of the tumor (meaning if the tumor can be removed completely)
    • Overall health of the individual: Individuals with overall excellent health have better prognosis compared to those with poor health
    • Age of the individual: Older individuals generally have poorer prognosis than younger individuals
    • Whether the tumor is occurring for the first time, or is a recurrent tumor. Recurring tumors have a poorer prognosis compared to tumors that do not recur
    • Response to treatment: Tumors that respond to treatment have better prognosis compared to tumors that do not respond so well to treatment

Additional and Relevant Useful Information for Verrucous Squamous Cell Carcinoma of Skin:

There are multiple types of squamous cell carcinoma of skin. These include:

  • Acantholytic Squamous Cell Carcinoma of Skin
  • Spindle Cell Squamous Cell Carcinoma of Skin
  • Verrucous Squamous Cell Carcinoma of Skin
  • Pseudovascular Squamous Cell Carcinoma of Skin
  • Adenosquamous Carcinoma of Skin
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On the Article

Krish Tangella MD, MBA picture
Approved by

Krish Tangella MD, MBA

Pathology, Medical Editorial Board, DoveMed Team
Lester Fahrner, MD picture
Reviewed by

Lester Fahrner, MD

Chief Medical Officer, DoveMed Team

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