Macroscopically, VC usually presents as a large, broad based exophytic tumour with a white keratotic and warty surface. On the cut surface, it is firm or hard, tan to white, and may show keratin-filled surface clefts. It is usually large by the time of diagnosis, measuring up to 10 cm in its greatest dimension.
Microscopically, VCs consist of thickened club-shaped filiform projections lined with thick, well-differentiated squamous epithelium with marked surface ke-ratinisation ("church-spire" keratosis). The squamous epithelial cells in VCs are large  and lack the usual cytologic criteria of malignancy. Mitoses are rare, and are only observed in the suprabasal layer; there are no abnormal mitoses. VCs invade the subjacent stroma with well-defined pushing rather than infiltrative borders (Fig. 1.15). A lymphoplasmacytic inflammatory response is common in the stroma.
Hybrid (mixed) tumours also exist composed of VC and conventional well-differentiated SCC; the reported incidence for the oral cavity and the larynx is 20 and 10%  respectively. It is important to recognise such hybrid tumours as foci of conventional SCC in an otherwise typical VC indicate a potential for metastasis. Orvi-das et al. reported that a patient with a hybrid carcinoma of the larynx died of the disease . Patients with hybrid carcinomas must be treated aggressively as if they had conventional SCCs .
Verrucous carcinoma is characterised by a high frequency of initial misdiagnosis; Orvidas et al. reported a series of 53 laryngeal VCs; 16 out of 31 patients (52%) had received an incorrect diagnosis of a benign lesion . This emphasises the need for close cooperation between the pathologist and the clinician in order to establish the diagnosis of VC. An adequate, full-thickness biopsy specimen must be taken when a clini cian suspects a VC ; moreover, multiple biopsies may be needed to rule out a conventional SCC component in a VC.
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